so I want you to understand that you have a brain the back part of it is where you learn the front part is where you do knowledge performance knowing doing and ADHD splits them apart I don't care what you know you won't use it you can be the brightest kid in the world not going to matter so you got a real problem on your hands because you can know stuff and you won't do stuff that's a serious problem called a performance Disorder so what we know about ADHD is it's going to put all five of those levels at risk because it interferes with all seven executive functions and you're going to have time blindness and you won't be able to aim your behavior toward the future to care for yourself as effectively as other people are able to do you have intention deficit disorder you have a disorder of performance not knowledge you know what to do but can't do it you have a disorder of the when and the where not the what and the how your problem is not with knowing what to do it's with doing what you know what does that mean it means that all interv ventions must be out at that place in the environment where you're not doing what you know to help you show what you know I have to create scaffolding around you to help you do this what does this mean for treatment teaching skills is inadequate it won't work you can sit down with somebody with ADHD and tell them what they need to do good luck right it's not even going to leave your office you act like they're stupid they're not they know what to do they know what you're telling them to do right they're not going to do it when they get out there that information has no controlling value over their life and it ticks you off you start to interpret it as a motivational problem but the only way to deal with executive deficits is to re-engineer the environment around them to help them show what they know and all treatments must be out there in their life where you have to build that scaffolding all of this in ADHD is due to neurogenetic deficits and that means that medication is absolutely justifiable after all if you have a neurogenetic disorder then neurogenetic therapies have a role to play in your disorder and they do 80% of people with ADHD will be on medication at some point in their life and good thing it's the most effective thing we have there are other things we can do but that's the most effective now you might be able to train up some of these executive functions we don't know that yet we don't know whether practicing working memory actually helped you in life there's no evidence that it does at this point at least convincingly but there's a possibility what we do know is we are not to excuse you from your mistakes because the problem you're having is not with consequences so why would I excuse them the problem you're having is with the delay to the consequence all important social consequences are delayed consequences and that's your problem time so the solution to anybody's problem with an executive deficit is to tighten up accountability to make you more accountable more often to other people with more consequences artificial as they may need to be but I need to bring consequences very close to you in time so I'm not going to excuse your behavior I'm actually going to hold you more accountable than other people and that is why we do bod bod allows me to sprinkle artificial consequences all throughout the environment to improve your functioning and that means that the success of my intervention is based on the willingness of other people in the natural environment to make those changes if they're not willing to build ramps so to speak to build the scaffolding it's not going to work the stakeholders have to be involved it means that ADHD is the diabetes of Psychiatry it's a chronic disorder that must be managed every day to prevent the secondary harms it's going to cause but there is no cure for this disorder now about one in six people might outgrow it maybe as many as one and three not sure yet but the vast majority two-thirds are going to continue to be ADHD in adulthood and they need to view ADHD as diabetes of the brain it's a chronic Disorder so here are the things that my theory tells you to do to help people with executive deficits this is what I told you this morning this is the take-home cash value of Shifting your framework from an attention disorder to an executive disorder and the theory tells you all six things you got to do step one you have to make mental information physical you must externalize the information because working memory is shot that means we have to use cues signs charts reminders doist I got to put stuff in your visual field to remind you of what needs to be done right here right now make it external again the next thing I have to do is make time physical real through clocks timers counters watch minders anything I can enlist that is going to put time outside of you so that you can see it passing and judge your performance relative to it because you have no clock we got to put one in in your visual field I'm going to have to take lengthy assignments because they involve spans of time and get rid of time make them small quotas little baby steps over the bridge in time a little bit of work done frequently over time and will get you there but you will not do book reports and science projects and other things on your own you can't those involve delays and you can't handle delays so the best way to solve the problem is get rid of the delay and bring it back into the now through Little Steps break all long-term projects into baby steps do a baby step a day you get there and if you don't do that they're not doing it you have to make motivation external they can't create internal motivation they are dependent on the environment for their motivation you must put the consequences in the now or they will not work for you this is what video games do and what homework does not which is why they can play video games for hours and not do their homework for more than a few minutes video Gam games provide external continuous reinforcement homework does nothing video games do not need ex or internal motivation whereas homework does so you've got to create motivation you're going to start to have to make a deal with your kids what's in it for them what are you putting in it for them what are you creating what's the reward what's the points what's the token What's the sex the drugs and the money whatever it is you're going to have to negotiate a deal there has to be a consequence or it isn't going to get done you have to make problem solving manual remember they cannot do mental manipulations like other people this is why they can't do digit span backward but it has nothing to do with digit span they can't hold things in mind and move them around as well as other people so don't make them do it put it in their hands if they have a math problem to solve give them marbles a number line and a Backus a calculator let them do the problem manually or at least assists the mental problem solving with manual pieces to it it's the principle that matters people you can come up with lots of ideas here and then finally and this is the most important the executive system has a limited fuel tank and you can spend it out real quick every time you use an executive function and you use it continuously you empty the tank and if you get to the bottom of the tank in the next situation you will have no self-control this is the ADHD child after school gone and you want to do homework you're out of your mind so you got to refuel that tank and that tank has a very limited capacity so how do we refuel the tank interesting there are lots of things we have discovered to boost the tank the use of rewards and positive emotions the use of self- statements of Effectiveness I can do this I know I can do this this is the locker room pep talk before the game helps to boost motivation in addition to that you need to take 10-minute breaks very often indeed more often you need to break pass down into smaller units and take frequent breaks and during those breaks a little relaxation and meditation helps to refuel the tank stop using the executive system for a few minutes and give it a chance to restore its fuel tank this is why we talk about the 10 and three rule with ADHD children 10 minutes of work three minute break 10 and three 10 and three but you can't do more than 10 you're starting to empty the tank give them a chance to refuel the tank what does it say about keeping Kids In For Recess when they don't get all their homework done you just shot yourself in the foot and that leads me to the next thing visualizing and talking about the future rewards will help you boost the tank and so does physical exercise routine aerobic exercise boosts the tank refuels it and creates a bigger tank everybody with ADHD should be involved in an exercise program because research shows it benefits this disorder better than any other psychiatric disorder and now you know why it's helps to refuel that tank and finally the fuel in the tank is sugar in the bloodstream in the frontal lobe blood glucose in the frontal lobe is directly correlated with executive abilities what does that mean if you have an extensive task involving your executive brain like an exam that you have to do you better be sipping on some lemonade or a Gatorade or a sports drink sipping not gulping right you're going to have to keep your blood sugar way up so that you keep this fuel tank partially restored so this is the opposite of what people once thought sugar hurts people with ADHD no it does not and never did but it may well help them if it's in fluid form that can get into the brain very quickly you got to keep that blood glucose up those are the things you can do to boost the fuel tank there are various approaches on the market for adults and college students with ADHD that incorporate these ideas Steve's or Russ Ramsey's program which is cognitive behavioral therapy does a pretty good job of it I'm not going to go through this with you Steve saffron's program even better because it's based on this model of executive functioning so Steve talks about what you can do to boost executive functioning in adults who are on medication but they have to be on medication and the most recent one came out this March it is the most heavily executive in nature it is Mary Santo's program for training executive functioning in adults with ADHD these are the three tested programs that have been shown to boost medication effects in adults with ADHD and all of them Target those deficits in the executive brain as part of their models so what have you learned today you've learned that ADHD is not an attention disorder you've learned that it's an executive disorder that the executive system is a very complex multi-level system like driving it is not one level of cognition and that's all it is it's multi-level it's complex and it extends into our daily life you know that ADHD disrupts that system through behavioral Innovation and wiping out all the other executive abilities which puts you at risk for failing in your executive activities in your daily life people with ADHD have problems in all dimensions of executive functioning in their daily life and that is going to lead them to have great difficulty in getting along with other people building up friendships networks cooperatives subordinating their interest to others all the things in that involve executive functioning from money management to driving to friendships to families and so on are at grave risk in this disorder because they all depend on this executive system so we are going to have to help people with ADHD build the scaffolding around them and use the medication as neurogenetic therapy with them in order to compensate for these executive deficits we're going to have to design prosthetic environments around them you know the beauty of ADHD is it's the most treatable dis disorder in Psychiatry there is no disorder that we treat that has as many medications and as many psychosocial treatments that are as effective as these are for as many people producing more change than any other medications and psychosocial treatments for these individuals do you know that 55% of people on medication are normalized 90% of them respond do you know that the effects of ADHD medications are three times that of anxiety drugs and anti-depressants that you all give away like candy in your practice we have huge effective drugs on our hands here that we can use and we also have very effective psychosocial interventions this is the most treatable disorder that we Face the biggest problem is most people don't get treatment 40% of children and 90% of adults with adht are not recognized or treated for their disorder that's the problem not that we're overtreating we are undertreating and we're undertreating the most treatable disorder in Psychiatry thank you welcome you are welcome right on time shall I close the fire hydrant I know you're all going no more no more I can't take it there's too much information right luckily this will be on the internet so you need to go back and review it and you have your handouts as well so we are going to proceed with questions now we've collected your questions we've sorted them into categories we've weeded out redundancy also these cannot be personal questions because that's unethical so we're going to try to keep them on the topic and not about a person and they're going to read them to me right so wrong pile Oh okay wrong pile as Dr bar said