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Jason Salotti

Essential Ideas for Parents

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Thank you what is largely, I believe, a group of parents and loved ones of people with ADHD. And so she wanted me to do something a little new and a little different. And I sat down and I said, you know, What ideas would I want any family that we had seen in our clinic to understand by the time we had finished working with that family, by the time we'd finished the evaluation and the evaluation the counseling of that family, what would be the 30 take-home ideas? I tried to reduce it to 10, by the way, but that's just not possible. And 30 was even a bit of a struggle.

There's another 30 I left out. But I think of these as sort of the touchstone ideas that a family needs to understand if they really are going to appreciate that both the nature of this disorder in a child and in a family you and what it means for the raising and management of that child successfully. So we're going to have some fun with this because I've not done this presentation in this way ever before and you may advise me never to do it again. We'll see. Obviously, the first idea is to know the disorder and we begin at a very elementary stage of this disorder.

This is a developmental disability That is the first thing you need to understand. A disability of what? There are two psychological traits that are not developing in this child on time So, let's clarify that. A developmental disability means that you are showing age-inappropriate behavior. It doesn't mean that your behavior is pathological It just means it's not appropriate for your age So understand one thing, ADHD is different from normal in a quantitative way not a qualitative way Developmental disorders differ from psychopathologies.

A psychopathology is a gross aberration in your behavior that we can recognize at any age if you are bipolar, if you are schizophrenic If you have major depression, we don't need to adjust the criteria for your age Because those are grossly abnormal conditions.

Autism would be another one Those are not developmental disabilities A developmental disability is a delay in the rate of a normal trait What distinguishes this child from other children who don't have the disorder is the degree of the delay they will go through the same stages that others would go through in normal development but not at the same time And when these traits reach their ultimate maturity, which by the way is your early 30s The person with ADHD will be leveling off at a degree well behind that of where the general population has leveled off in that trait So delay does not mean lag, it doesn't mean temporary This is a chronic lag in the development of these traits.

But the important thing is that the difference between this child and other children is quantitative It is like someone sitting next to you who is shorter or taller It is like someone who is more athletic or less athletic. These are not qualitative differences They're quantitative So that is what separates your child from others. The degree of the delay is the distinction. I say this because so many trade books written for parents have argued that ADHD is a qualitatively different human Your child is a little hunter and he has to go to school with farmers. Your child has a gift that other children do not have. This is nonsense.

This is utter gibberish There never was nor will be any science that would support those ideas ADHD is not a qualitative different state of humanity from other people It is much more like being better or worse at writing, taller or shorter in your height better or worse at language. Those are quantitative differences. That's important because otherwise we stigmatize these people as coming from a different planet. You know, one is from Venus, another from Mars, to popularize or to take up a popular view of gender differences between people men and women, but you get the point People with ADHD are not different from normal, other than in the degree of the delay.

Now, what is it that is delayed? Two traits The first is not the one after which the disorder is named In that sense, the disorder has been misnamed The first deficit to appear is inhibition a failure to develop an appropriate inhibition of your behavior And this will often emerge in the preschool years. And its first sign is usually hyperactivity, though it doesn't need to be so But it typically is. You have an individual who is behaving too much who is not suppressing irrelevant behavior the way other children are able to do We will see this in their motor actions. There's a lot of action coming out of this child. We will see it in their verbal behavior.

There's a lot of words coming out of this individual And we will see it in their intrusive and disruptive motor and verbal behavior as well. But along with that, There is a cognitive impulsiveness this snap decision making, this quickness to do the first thing that pops into your head without due delay and due diligence, thinking about what the consequences will be and then we will also see the restlessness Not just the gross motor activity, but the seat restlessness which I think affects their school performance more than the gross motor activity does.

But this will decline with age, so that is why hyperactivity is no longer the name of this disorder because it declines deeply, and by adolescence, it's nearly gone, and by adulthood, it's an internal state It's a feeling inwardly of a need to be busy and doing multiple things. And it's a busyness of one's mind, one's ideas. There was a restless quality to their cognition but not to their outward behavior. In fact, our research has shown that hyperactivity is of no diagnostic value in adulthood In fact, being restless is more associated with anxiety disorders by the time you're 30 than it is being associated with ADHD. We just don't pay attention to it.

It's of no relevance to diagnosis So let's understand that the real problem here is not restlessness, it is in fact inhibition There is a failure to develop appropriate in addition. And it affects your behavior. It affects your words It affects your mind and your thoughts and we need to return to the idea which we have gotten rid of that it affects your emotions. For the first 170 years of the history of ADHD in the medical literature, which began in 1798, not 1902, the history of ADHD is a history of mental health.

It's a history of mental health eight years ago The last remaining copy of a medical textbook was discovered at Kent State University This textbook was written by the Scottish physician, then living in colonial America Alexander Crichton. And Crichton had written a medical textbook in which there is a chapter entitled Diseases of Attention And it is the first description of this disorder. And it's very good, by the way So ADHD did not begin in 1902. It started in 1798 as far as the first initial medical reference. And from that point on until 1976, Emotion was part of ADHD Every major theorist, every paper, every science paper, including that of Mark Stewart, one of the first major scientific descriptions.

The Canadian papers by Weiss and Heckman and Wary and Douglas and others back in the 60s and 70s all included emotional impulsiveness as part of this disorder But the DSM parsed it aside and made it an associated problem in some people it isn't It is as much a core feature of this disorder as is any other symptom in the DSM And that was our mistake and it needs to be returned to our understanding of ADHD By emotional impulsiveness, I mean this quickness to anger, to be easily excitable, to have low frustration tolerance to be easily angered by things around you and to display your emotions much more quickly than other people do Now this is not a mood disorder, even though it starts to look like one Mood disorders are where you are generating too much emotion What ADHD is, is a failure to regulate normal emotion It is a self-regulation disorder The feeling you're having is normal, that you are not moderating it is not It is this inability to self-soothe to self-calm and to then moderate the emotion to be more acceptable for the context and for what you hope to accomplish here, the goal that is at hand.

Your long-term welfare is at stake Can you modify that emotion? to be more socially acceptable, to be less costly, less damaging That is as much a part of ADHD as anything else, and we are pushing the DSM-5 committees There are several to reincorporate emotional impulsiveness and this emotional dysregulation as being a part of this disorder because it loads on this dimension You cannot be impulsive in your behavior and not be impulsive in your emotions.

That is impossible because they are a unity They go together Emotion is welded to everything you say and do Sometimes it is benign and bland Other times it is powerful and intense It is the emotional coloring of the behavior we display If you are impulsive in one, you must be in the other That needs to get reintroduced back into ADHD for a number of compelling reasons, not just because historically it was always there but because it explains so much more than the current view of ADHD explains As I will show you, ADHD children are 11 times more likely to develop oppositional defiant disorder within two years of the onset of their ADHD.

Why? What do those disorders have to do with each other? Now they're treated as simply comorbidity. Oh well, they go together, but we're not sure But if you put emotion back into ADHD, you see the connection right into ODD.

Because everybody with ADHD is automatically subclinically ODD at the get-go it's only going to take one more symptom to cross the diagnostic threshold In other words, ADHD causes ODD That is an important thing to understand because the ODD, while it does have some social influences over it Half of ODD is the inability to manage frustration, impatience, and anger And that will set you up for the second component of ODD, which is interaction conflict defiance arguing but the first four symptoms of the eight in ODD our mood anger, temper, hostility, easily annoyed, irritability And that is part of ADHD So we need DSM-5 and we need families to both understand that emotion goes with this disorder It is not a separate comorbidity in some cases.

And now we know why when we treat ADHD particularly with the medications that we use we get nearly as much reduction in ODD as we get in ADHD.

And when we don't It is because of the social conflict component which is learned and we will have to unlearn that little piece, but the mood component is the ADHD component you Now by returning emotion into ADHD, it also helps families to understand some of the other life course risks 50 to 70% of ADHD children are utterly rejected by close friendships by second grade It is, in fact, one of the more devastating consequences of this disorder is this inability to make and keep close, sustained friendships with other children and it is heartbreaking for parents to see this happening that their child is not as liked as other children.

That the sleepovers, the going to the movies, and the other social events in which other children celebrate their peer relationships are shut off for this child Why is it there? The single best predictor of peer rejection is that symptom emotional impulsiveness Friends forgive you your distractibility, your forgetfulness, your working memory problems, and even your restlessness They will not forgive your anger, your hostility, the quickness with which you emote to other people because it is offensive It is socially costly. So now we can begin to understand the numerous social problems that ADHD children are prone to, because it arises from this aspect of the world of the inhibitory deficit There are other things that it explains.

I could do a whole hour and a half as I did a month ago in Toronto on the importance of emotion in ADHD.

I won't go there But suffice to say that it explains the road rage during driving the job dismissals, which are not the result of inattentiveness but of being too quick to anger too quick to express raw emotion in the workplace of which employers are not tolerant, especially if it occurs with a customer And it also explains to us the marital difficulties and the parenting difficulties these children may be prone to because the single best predictor of marital problems in the adult with ADHD is not distractibility It is emotion So we can begin to paint a better picture of understanding ADHD and its life course risks by understanding the nature of the inhibitory problem and that it includes emotion as part of it And that's just slide one.

I've got 85 slides. Do you see why I'm concerned? Fifteen minutes to do a slide. All right, so we better get rolling here. But I thought you ought to know where we're going. And by the way, in case you hadn't noticed, I will not talk down here to you today I will treat you as if you were my colleagues, my students, my peers because I think that parents attend these things to learn And that's not going to happen if I have to dumb this material down And it is also insulting. And I won't insult your intelligence either. You're knowledgeable people I'll speak to you frankly using the scientific terminology. Thank you.

Oh, please.

Thank you The second dimension failing to develop on schedule attention deficit, but it isn't Here again we have a misnomer There are at least six or seven kinds of attention and supporting networks in the human brain They are not all disrupted by this disorder What we want to know is, which one? to help us with differential diagnosis, to help us tell ADHD from an anxiety disorder and from autism and all the other psychiatric disorders, which all interfere with attention at some point in life ADHD is not the only attention deficit We need to be more precise If someone comes to us and says, my child, or I am inattentive, that is useless diagnostically What I need to know is the nature of the inattentiveness and we have now known for a decade that the inattentiveness that we see in ADHD is distinct from that produced by all other disorders because it is most I think accurately described as a failure of persistence The first attention problem is persistence toward a goal Notice that this implies behavior motivation, and the future That is very important.

The other forms of attention do not ADHD is not a problem of perception, of filtering, of processing of how the posterior part of our brain functions. It is a problem with the motor part of the brain, this frontal lobe Can you sustain action toward a goal? adequately to attain it That implies a motivation deficit, and that is true and it implies future directed behavior, and that is true ADHD is a failure to direct behavior forward in time We cannot persist toward these delayed endpoints in life, the tasks, the goals, the things that need to get done So persistence is deficit one in the area of attention.

Now to persist toward a goal, you must be able to resist distractions But that too is not a perceptual issue. It is a motor issue The person with ADHD does not have problems with perceiving distractors better than others It is that they respond to distractors more than others And that is an inhibitory failure, not a perceptual difference you and I may all hear the noise in the kitchen The person with ADHD is compelled to react to it. Oh, did you hear that? I guess they're washing dishes. Maybe I'll stop in and take a look. Did you know I was a dishwasher when I was back in college? That's how I earned my way.

Do you see what's going on here? You all heard the dish, but it was irrelevant to what we're here to do today But to the ADHD individual, the distraction is going to provoke a response, and the response can't be inhibited And now they're off to the races, skipping from one thing to another to another Now, there is a third aspect here that is impaired but it is not one of attention Most people, when they are distracted, re-engage the incompleted goal The person with ADHD is far less likely to do so.

And this has nothing to do with attention This is working memory So I would want a family to understand that there's more here than inattentiveness there was a working memory disorder And I would want them to know that working memory is one of the five special executive functions of the human brain suggesting that ADHD is EFDD executive function deficit disorder. Because working memory is where we remember what we're doing It is remembering so as to do. It is consciously, effortfully holding in mind The what, the when of what we are doing It's what you lose at my age and when you hit menopause. You do not lose memory you lose working memory.

You forget what you were doing where you were going, what the goal was the steps to the goal, how you were getting there It is that that allows you to re-engage the incompleted goal because you are holding in mind the goal It is that which ADHD children and adults will lose The goal is gone It is forgotten And now anything else compelling around them will capture their behavior Hence the symptom skips from one incompleted activity to another The ability to re-engage a goal is a working memory disorder And that's what they cannot do. And this begins to open the door on the possibility that the other four executive functions are impaired as well.

More on that later So, let's understand that there are three interacting attentional problems but that they are best thought of as executive deficits not attention deficits and they are the problem with persistence toward the future resistance of distractions along the way And we'll see you next time working memory And now you understand the nature of this attention problem the one that's produced by anxiety and depression and autism and all the other disorders including the learning disabilities which have nothing to do with these I would want families to understand that there is more to ADHD than just the inhibition and these attention and working memory problems. That at its heart, it's a problem In its soul, it is a disorder of self-regulation not one of attention.

I think the biggest problem we have had as a group in convincing the general public about the seriousness of our children's disorder versus autism or schizophrenia or the other disorders is the very name itself. It's trivial ADHD, go to Starbucks, good God. Have some caffeine.

We got more serious fish to fry here in psychiatry than the fact that you just can't pay attention, right? Part of the reason that our disorder, that the name of this disorder, is so often pilloried in the media is because I think we misnamed it This is a developmental disorder of self-regulation not of attention And that is a serious disorder as serious as manic depression and in its own way as autism But it doesn't convey that to people if they understand it only as ADHD as opposed to SRDD a self-regulatory developmental disorder So I would want families to understand the seriousness of this that this isn't simply inattention.

There are some profoundly unique human traits that are not emerging as they should in this individual And if you'll understand that, you'll understand the bigger picture, the why of everything. If it's just an attention problem, why am I seeing impairment in virtually every domain? in which this child is asked to function That would not come from just inattentiveness but it would come from an executive function disorder a self-regulatory disorder.

So I would want parents to understand that this is the essence of this disorder self-regulation What is that? It is, first of all, the ability to consciously be aware willfully choose to inhibit your behavior and then to engage in a series of self-directed actions That is, after all, what self-control is you start to do things to yourself These are responses that are not directed at the world around you, they're directed at you You're trying to change your behavior in some fundamental way The second part of self-control that your child struggles is not just the stopping but the thinking The thinking is the self-directed activity, the stuff I am doing to myself Why would I do these things to myself? to change my behavior from what it would otherwise be, and why would I do that? to change my future Self-regulation is not just for short-term self-improvement It's for long-term self-improvement.

It's to see to your own welfare over the long term Should you act this way? given the sustained or delayed consequences that lie ahead for you. That is what you must stop and think about And that is what they don't stop and think about the delayed consequences So your child is not just inattentive They cannot stop and engage in a series of self-directed actions that they will now use to modify and moderate their behavior so as to bring it in line with their long-term welfare the future And that's what your child is struggling so mightily with in their development.

It's what the other kids are acquiring, and your child is so far behind him I would want parents to understand something that the vast majority of the lay population does not understand Self-control is not learned It is not the result of your upbringing and how good your parents were. This is one of the most profound insights from our research on ADHD ADHD, as we will see, is largely a neurogenetic disorder but then let's pursue the implication.

If that is true and ADHD is a self-regulation disorder, then self-control is largely neurogenetic in origin That has a philosophically profound conclusion The vast majority of variation in the people sitting in this room and their ability to manage their behavior is not from how they were raised It is a part of who they are.

It is a part of their neurogenetic gifts And that is very stunning indeed that our capacity for regulating ourselves is a neurobiological trait not some socially learned phenomena that you just happened to pick up from your parents So I would want them to know that ADHD is not a disease being a self-regulation disorder is arising out of neurogenetic causes and that this inability to direct behavior toward yourself comes from impairments in the following five executive abilities And these have to do with brain development not with training It does not mean that training cannot enhance them It means that they don't originate at the beginning in training in the social environment The social environment requires that they be there already and then it will help to shape them to become more proficient.

Think of your language ability. You didn't learn language but it doesn't mean that you can't become more proficient in how you speak and how you write but speaking and writing are not accounted for on the basis merely of training by your parents you're going to develop a language no matter where you grow up that is a neurobiological trait and it unfolds as the brain unfolds It is an instinct and so is self-control But self-control can be reduced to these five things What are the five things you do to yourself? These are the things your child struggles to do.

Number one Can you stop? Can you wait? because as Rabelais said in the novel Gargantua, which most of you have never read, I'm sure but it is where this phrase comes from Everything comes to those who can wait The waiting is the tough part You must build in a pause between the event and what you plan to do about it And in ADHD, there is no pause The event happens and your response is up, out, done Is it as if there was no front part to the brain? It is as if you were like any other species with a spinal cord. Event, response, event, response or as in a Gary Larson cartoon, Member of the Far Side Two amoebas, a husband and wife, talking to each other.

One amoeba, the wife, of course, says to her husband Stimulus response, stimulus response. Don't you ever think? Characterizes ADHD right there Don't you ever think Once you stop, you will engage in four subsequent actions. The first is mental imagery You will recall the past and you will play a DVD of it in your head You have a theater in your mind It is your visual imagery system you the mind's eye So your child not only cannot stop They cannot visualize as well as other children.

And what they do not visualize before they act is the past the relevant past Do you have experiences in this situation previously? If so, what would they have told you to do? Laypeople call this hindsight, and the word sight is no coincidence you are visually imagining your history What does it have to say? and you lack hindsight Now this will lead to foresight You look back to anticipate What does ADHD lead to? No foresight You are not thinking ahead because you weren't looking back either hindsight, and foresight are the opposite sides of the same coin visual imagery So you will not use your images of your past to tell you what to do you will just do And then by five years of age, you will get the third executive deficit You can't talk to yourself Young children by five years of age are beginning to internalize their speech and use it on themselves.

Just watch any first and second grade classroom and you will see this If you have a three to five year old, you'll hear it.

They're talking to themselves out loud most of the day, whether anyone is in the room or not Listen to bedtime and you will hear what I mean But over the next 10 years, this external voice gets directed to themselves and slowly made private and mental in its form And so originates the voice in your head And that voice in your head is there for one very important reason It's to help control yourself you start telling yourself what to do and it starts to work And now, any family I would explain this to would understand that not only can your child not stop, and only do they not have the mind's eye, they don't have the mind's voice And what is there is very weak it's not controlling them So now you know why they can't do what you tell them to do They can't follow instructions, they can't follow rules, they can't internalize the rules of the situation, because everything I have just said requires a voice in your head and they don't have that Thank you The next comes from the first three, and that is the mind's heart The ability to manage your emotions so that they are more socially acceptable so that they are consistent with your goals not conflicting with your welfare And so we will see the ADHD child as we've already described them easily frustrated, quick to anger, impatient, and just overall more excitable and more emotional than others.

But what gets lost in this explanation is something more fundamental our emotions are our motivations if you cannot manage your emotions you cannot manage your motivation either Because the fourth executive ability is the source of self-motivation Self-motivation is the fuel tank for all future directed behavior There is no getting ready for tomorrow if there is no self-motivation So what is the ADHD child lost here? They cannot motivate themselves What does that mean? It means that you will always be dependent on the environment around you and its immediate consequences for how hard and how long you can work And if there are no consequences in that context You cannot work You cannot persist You will not get it done The fourth executive ability now explains to these parents why this child can play video games for hours and cannot do homework for more than a few minutes because the video game provides external, continuous, 100% consequences for interacting with it and the homework does nothing When a problem is solved on a sheet of paper, nothing happens.

The consequences are delayed And therein lies the trouble So the corollary of this is if you want to see an ADHD person fail, you put them in any environment where there are no consequences and I guarantee you failure The work will not get done because the person cannot self-motivate. And this is not a choice, and this is not willful, and this is not a child who just could, if they wished, wake up tomorrow and smell the coffee and get busy and do the work They cannot, this is an internal neurogenetic executive Failure you can't self-motivate like other people.

So it doesn't matter what your goals are, you won't get there because self-motivation is required for all goal-directed action The final executive ability which will not emerge until late childhood in the person with ADHD is the mind's playground This is the ability to plan and problem solve How many different possible options can you generate right now? to get around this problem this ability to simulate multiple possible future options is the highest executive function in humans It is the source of all cultural innovation but it originates in problem solving how quickly in your mind Can you think of multiple ways to overcome the problem you just encountered? And people with ADHD will struggle with this one as much as with the others So if you want to understand ADHD as a parent, you have got to understand these are the five things that are delayed in this child the ability to stop, to use visual imagery, to use your mind's voice, to use your mind's heart and emotion and motivation and when called upon to do so to simulate multiple possibilities when faced with a problem or when planning out what you hope to do planning and problem solving Those are the five executive abilities.

We know where they are in the frontal lobe. We know that ADHD children have lost all five of them Actually, that's a bit of an overstatement It's not that they don't have them. It's that they are quite delayed. And we will discuss the delay in a moment So ADHD leads you to act on impulse not resist distraction. You are less able to think back about what you are doing, about the action that lies ahead. You cannot use your hindsight, and therefore your foresight is gone.

You do not plan ahead You live in the moment This is going to rob you of your sense of time, because the sense of time comes from looking back to look ahead looking across time and knowing where I'm going you will not have a subjective sense of time and that alone is going to be a devastating adult disability you have the consummate disorder of time management It's no wonder they're always late You will not be able to talk to yourself, to reason with yourself, to ask yourself questions, and to remind yourself of the rules that are governing the immediate situation And therefore it doesn't matter what people say to you over and over and over again.

You won't do it no amount of nattering by your teacher or your mother will overcome the internal mind's voice deficit you will not be able to use language as well as other people to regulate yourself And that is going to also lead you to have a self-motivation problem and a problem with regulating your emotions and with self-soothing when you do become emotional And then as we've said, you will have trouble with planning and problem solving. So if you want to know the symptom list of ADHD, this is it The DSM is but a mere superficial reflection of the most obvious symptoms of these five executive deficits.

But to truly understand ADHD, you need to know that these five are all there underneath To refer to ADHD as inattention is to refer to autism as hand-flapping and speaking funny They are the most obvious symptoms of a failure to develop the ability to relate to others as special objects as humans And that is what autism really is underneath The rest of it is just the most superficial set of symptoms So I would want my family to understand the profundity of these deficits because inattention hardly captures what is going wrong in development Now the DSM says there are three kinds of ADHD.

Let's shift gears here and get honest There was not a combined inattentive or hyperactive type and DSM-5 will abandon them They are contaminated with each other because there really is only a single ADHD in the human population.

And it varies in its severity, and all these types have done is to capture the degree of severity of a single disorder So we are now grappling for ways of subgrouping people with ADHD that is more clinically useful than the DSM view is, because the DSM view is useless and one of those ways that is very compelling is ADHD with and without conduct disorder The Europeans have done this for decades In the North American continent, we viewed conduct disorder as a comorbidity We are now looking at it as a subgrouping criteria because you see ADHD children who have conduct disorder differ from ADHD children without it in many, many respects.

So many, in fact, that we are now coming to think of this subset of children who have both disorders as a unique problem form of ADHD Because both disorders are more severe. Both disorders start earlier.

Both disorders are far more persistent and the combination of these disorders will predict ongoing difficulties with antisocial behavior into adulthood and just as important These individuals carry a high risk for psychopathy One in five of these children is a budding psychopath a child who lacks guilt conscience Empathy remorse a child who is a predator ADHD does not contribute to psychopathy But ADHD with conduct disorder is the single best predictor of the psychopath that we know of So in the future, we may be making the same distinction the Europeans have that when conduct disorder and ADHD go together, we have an extraordinarily virulent disorder In case you're not familiar with conduct disorder, it is the early appearance of lying, stealing, fighting, and preying on other children in an instrumental way It is violating the rights of other people for your own gain and it manifests early as the lying, the stealing, and the fighting.

But other symptoms will develop thereafter The hyperactive type of ADHD never existed because 90% of all cases go on to get the combined type within three years And even if they don't get the combined type, they're just one symptom short And so we call them subthreshold combined types, but they're not a different type So if we take these two groups of children who really are just variations on the good old combined type of ADHD, that's 95% of all the kids put into this group There is a small group left over who are purely oppositional But because they have pure oppositional disorder and they never had ADHD, they will outgrow their ODD, usually within two to four years and their ADHD will go away Why are they there? Because parents confuse ODD with ADHD.

And if their child is only oppositional, they often report that they have symptoms of ADHD when they don't But ODD alone is a relatively benign disorder unless it goes with ADHD and that it is a highly persistent disorder Now, the real action during the past decade has been with this inattentive group of children, most of whom are combined-type children And they grew up, and they lost some hyperactivity along the way, as we said And as a result, there's going to come a time in adolescence, and especially by adulthood, where they're just not hyperactive enough to stay in the combined type anymore And so clinicians relabel them as inattentive type, but they shouldn't.

Once combined type, always combined type But you can see how at least half of the individuals get put into the inattentive group. They're just outgrowing their hyperactivity And then there's that group of children who just are one or two symptoms short of being in the combined type, but they have the combined type anyway.

They're just a milder version of it But interestingly 30 to 50 percent of the children who are now called inattentive type probably have a different disorder and researchers have called them SCT It's about 30 to 50% of all inattentive type children and we now believe this is a qualitatively unique disorder The debate now is whether this is a separate type of ADHD a point with which I disagree Or is it a qualitatively separate disorder? a point with which I agree Why would I view this as a different disorder? First of all, the symptoms are the opposite of ADHD but you won't see them anywhere in the DSM But these are the most compelling symptoms that go with SCT But because these children also have an attention problem, there is no place else to put them because ADHD is the only attention disorder in the DSM.

So they get dropped into ADHD even though they have no symptoms in common with it These individuals have a problem with processing information, which ADHD children do not have These children have trouble with focused attention, choosing what's important from what's not ADHD children do not.

Their problem is in persistence These people may have a long-term memory storage problem, or it could just be the same attention problem that appears when they search their memory What is quite distinct about them is that they are socially withdrawn reticent Shine apprehensive and often prone to social anxiety But certainly, socially reticent is a very good word for them This is not a word that would ever be applied to an ADHD child Most importantly and tellingly, they do not have an inhibition disorder and inhibition is the heart of ADHD and therefore they do not have a self-regulation disorder, and ADHD is a self-regulation disorder And these individuals do not have the executive deficits that I just listed for you that go with ADHD For those reasons alone you could argue that this is a distinct disorder, but there are others There was a very low rate of oppositional and conduct disorder associated with this type of child ODD and CD are much more common in ADHD children These children have more anxiety problems ADHD children, while one in four may have anxiety, it's far higher in this group We're not sure if depression goes with this group.

Both groups have about a 20 to 25% risk of depression, but it doesn't distinguish the two disorders When we interview families of these children, their parents are concerned only about school Nothing else These are good kids Not disruptive outside of school. They even have a few friends, not as many as other children but more than ADHD children will ever have So the big concern is, let's get that school work done and the mistakes they're making in school.

You interview the parent of an ADHD child, they're worried about everything Peer relationships, family functioning, community behavior Not to mention what happens as the teen gets older and starts driving and having a job and managing money and becoming sexually active SCT families, don't worry about any of that stuff ADHD families worry, and well, they should These children mainly have trouble with accuracy of schoolwork. They get all their work done and Half of it's wrong ADHD children, don't do any work So the difference, SCT is an accuracy disorder ADHD is a productivity disorder That's a qualitative difference.

Another one is that these children may be more prone to math disorders, but we're not sure about that These children come from quite different families families with the same kinds of problems higher rates of anxiety higher rates of learning problems in school That's about it Children with ADHD come from families with a lot more ADHD a lot more school failure a lot more antisocial behavior alcoholism Depression and drug abuse These children do not When we look at the treatments that work for these children, and this has not been very well studied by the way But even here, differences appear The medications for ADHD don't work very well for these children. They don't hurt them. You can try them.

The lowest doses are the best They just don't help them. In fact, in our study, only one in five children was kept on their medication after the trial In ADHD, it's 92% These children are the best responders to social skills training. But no surprise, social skills training was invented 40 years ago for shy people and we know it works best for shy people not for aggressive people And so these children actually do very well in social skills training ADHD children do not do well at all in social skills training If they do, it needs to be done in the school environment with the children they go to school with.

Now, I'm going to go to the next slide not in a summer camp, and certainly not in some Saturday morning clinic with other children they'll never see again the rest of their life If you're doing that, you're probably wasting your money So if they benefit, it's because they benefit by the teachers and others doing the training outside of the clinic environment in the natural setting where the social problems arise. And even then, it's not so much the skill training as prompting and curing and rewarding the occurrence of the skill.

Now do be aware that research now shows that one in four children put in a social skills group will be made worse by the group This is known as deviancy training, and it happens to occur because the more aggressive children in any peer group will train up the less aggressive children to become more aggressive, if only in self-defense. It happens every kindergarten year to normal children as well So clinicians need to be careful because there are side effects to social interventions 25% of ADHD children get worse by being in a social skills group, and we wish to avoid that.

Now, the MTA study has found that anxiety is the best predictor of response to the behavioral interventions We could argue, therefore, that SCT children are probably the best responders to behavior modification, even better than ADHD children are We know that cognitive therapy, which is teaching children to talk to themselves, fails for ADHD. We know why now, because the mind's voice is not developing on time And in order for talking to yourself to have any success you must have a normally developing internal speech and they don't at least not until adulthood. And then some cognitive training does help as a supplement to medication. But in childhood, cognitive training doesn't help ADHD. But this isn't ADHD.

So shouldn't we revisit this? and do cognitive training for SCT No one has done it. There's a dissertation. You know somebody who wants a dissertation? I just gave you one. I just gave you one What about medication? Well, we don't know We know the stimulants aren't particularly wonderful for them. They don't hurt them, but they don't help them all that much What else might work? Well, I don't know, honestly, but let me conjecture. If I were writing a grant tomorrow I might speculate that Stratera might work for these children only because these are more anxious children and stratera treats anxiety when it coexists with ADHD So maybe adamoxetine might have a shot at this disorder.

We don't know. Nobody's done it Another drug that might be interesting is Provigil modafinil Modafinil is an antinarcoleptic And it does seem to help people with ADHD. It might help this group even more, because you remember those symptoms I showed you two slides ago? Does that sound a little narcoleptic to you? Lethargic? slow moving drowsy staring inattentive Hmm, maybe a brain stab drug might help you. Again, all speculative.

We don't know By the way, that is all we do know on SCT, so please don't ask me any more questions about it, because you now know everything I know What I do want you to know as a family is to understand that that's not ADHD ADHD is quite different from that And so if you happen to have an SCT child, or you know someone who does Please don't tell them to read the books on ADHD. They will be sadly misinformed They will be told of all kinds of risks and all kinds of treatments, which as far as we know have little if any application to these children There is no book for parents on SCT.

Not yet nor should there be, we don't know enough But researchers are now studying these children. The very first Psychological treatments for SCT were published about a year ago at the University of California, San Francisco And so we're now beginning to see more and more research on SCT children as distinct from ADHD children.

But what I would want a family of an SCT child to understand is that is that this is an ADHD So what you should be worried about are not the things families of ADHD children should be worried about It's pretty much going to be a school-based issue and the treatments that don't work for those kids might well work for your child And the treatments that do work for those kids, such as medication, might not be so great for your child No harm, but not necessarily so great Now, the next point I'd like a family to understand, and we are only on number six. Whoa.

Twenty-five to go Bye! that the deficits in these executive abilities chiefly arise from problems with brain development. So we're going to do a very quick three minute crash course on causation What causes ADHD? multiple things but all of them fall into the realm of biology We now know that you cannot turn a normal child into an ADHD child by exposing them to any social influence Not possible Not gonna happen We also know that these causes can interact with each other. I'll show you a slide on that.

Very interesting multiple biological hazards may be interacting to produce the disorder We now know where in the head this is coming from So if someone tells you we don't know where in the brain it is, they're wrong go to the library, please read a journal We know that social factors alone do not cause this disorder, but social factors are very important. Kindly do not leave this room and say that Russ said that social factors don't matter. I didn't say that.

I said they don't cause it But they do matter in three important ways First, the resources you will have available to treat this child are very much a function of the social environment around you Second? The impairments your child will experience are very much a part of the situation you can rearrange environments so they're less impairing Third, comorbidity We know that other disorders that link up with ADHD have some social contributors to them oppositional disorder conduct disorder, anxiety disorder, and depression all have social contributions Indeed, 40 to 50% of the variation in those disorders is the social environment So, while the social environment doesn't cause this disorder, I would want families to understand that doesn't mean it's not important or irrelevant.

It's important for several other very important people important reasons Now, we know that a third of all ADHD is acquired not genetic And that most of those acquired cases occur during pregnancy. And these are the things that we have found that are likely to cause ADHD in the unborn child. Because all of these disrupt the formation of the frontal lobe of the brain But we also know that about 5% of ADHD can occur after birth as a result of various traumas and infections and other things that can affect ongoing brain development in these five crucial areas And it is the acquired cases that are most likely to have seizures.

We know that lead poisoning Treating leukemia, that's right, the treatments for leukemia can cause ADHD We know that strep bacteria contributes a small amount of ADHD Why would the strep bacteria do that? Because the strep bacteria has a protein on the outside of it And that protein is identical to proteins that occur in the brain and therefore your immune system attacks your brain So it's not the bacteria It's the fact that the immune system can't distinguish the bacteria from nerve cells and this damages certain parts of the brain and one of those parts causes ADHD.

It's not a very common problem, but it can happen We know the brain regions that are giving rise to ADHD, and we know that in 2 3rds of children, the reasons for these brain regions being smaller has to do with genetics, about which I will say more in a moment. But let's at least go through these brain regions The five regions of the brain that are interconnected to each other and give rise to this disorder are the right frontal lobe, right over here, especially over the eyebrow and the connections from there deep into the brain called the basal ganglia.

I'll show it to you in a moment And then there are connections from the central part of the brain back to the very primitive structure at the back of the brain known as the cerebellum That is also smaller And then there's a very special part of the brain that lies right between the eyes in the midline going back on the walls of the two hemispheres as they come together. And deep inside on those walls is the anterior cingulate and that is where the emotional dysregulation originates.

Finally, there is the corpus callosum, which allows the two hemispheres to talk to each other, but it's no surprise The front part of the brain is smaller than the corpus callosum, has to be smaller The size of this network is directly related to severity of ADHD And in children who inherit the disorder, these parts of the brain are about 3% to 10% smaller. That's it, just 3% to 10%. Doesn't sound like much, and it isn't but it's enough to cause this disorder More importantly, it's not enough to use brain imaging for diagnosis These differences are so small and so subtle that you could not use them to classify people which is why no brain imaging technique including Dr.

Amon's speck scanning is of any value for diagnosis We know that there are very few gender differences in these networks, though there are some that are interesting. I won't talk about them today And we know that these differences are relatively persistent over time The structural differences will normalize by about 16 to 18 years of age. That is the size of the brain but the functioning of the brain will not And contrary to Tom Cruise and the Scientologists, these brain differences have nothing to do with giving medication to these children So let me show you the parts of the brain we're talking about very quickly. Let me get my cursor up here on the screen.

This is the right orbital frontal area right here This part of the brain projects back in between those two hemispheres. There's a structure you can't see. It's right about in here. And that's the anterior cingulate And then there are projections back into the basal ganglia right here and then back to the cerebellum right there. And it's the right side of the cerebellum in the central part that's smaller.

Indeed, Most interesting is that research has found in the last two years that the parents and the brothers and sisters of ADHD children also have smaller neural networks in exactly these areas except for one and that is the cerebellum which tells us that of all of these differences, Most of them were part of the family phenotype even if the family member never shows the disorder They carry these patterns of underdevelopment What may make the disorder break through into full disorder? is that something happened to that cerebellum That's an interesting possibility. Remains to be replicated, but that's a finding from research at UCLA. So what's going on? The brain is not developing on time.

We know that from the Montreal, New York, Washington multi-site study in which 223 ADHD and normal children were scanned serially over a period of about 10 years.

This is the first developmental neuroimaging study And what did it find? that the frontal lobe of the brain, primarily, is about two to three years delayed in its growth This is a study of growth, not function just brain size And what you're looking at is a top-down view of the brain, and these are the frontal lobes So there's about a two to three year delay in your brain development, and you can see it in the right and in the left hemisphere here as well So this was a groundbreaking study demonstrating that the brain is late in these crucial executive areas to develop.

Now, The better parent is going to be asking me about this This is not the frontal lobe What the heck is that? That's back where your visual cortex is Why would that be involved in ADHD? The second executive function is visual imagery and that's involved in visual imagery you This part of the brain developed too early This is the Motor Strip And it developed about two to three years earlier and it's where the hyperactivity is coming from So you've got a motor strip that's generating behavior and a frontal lobe that's not regulating it So I would want parents to understand that this is a brain-based disorder and that it results in a maturational lag and how rapidly these parts of the brain are developing I want the family coming to my clinic to understand that most of these differences originate in genetics but that about a third of the male patients that we see may well have acquired their ADHD In girls, it's far less than that.

In fact, it's fair to say that the vast majority of girls have the genetic type of the disorder but about a third of the boys may have acquired their disorder. We know that ADHD runs in families and have for 40 years. Here are the risks if you have an ADHD child 25 to 35% of their brothers and sisters will have the same disorder. If you're an identical twin, that risk is 78 to 92% Notice that the closer people are genetically related, the higher the risk if one has the disorder that the other's gonna have the disorder.

Now, if we bring in their mothers and evaluate them, upwards of 1 5th of their mothers are still adults with ADHD and nearly a third of their fathers are currently ADHD. And if you add those two together, it means that there's a 50% chance that one of the parents sitting across your desk has the same disorder probably never diagnosed which is why we now teach clinicians that you should be screening every parent that brings a child to your clinic.

Oh, and by the way, if you're an adult with ADHD, 40 to 54% of your children will have the same disorder That is a profoundly genetic disorder Nearly half of the offspring of adults with ADHD have ADHD as well We know from twin studies that the vast majority of ADHD is due to genetic differences.

On average, 80% of the differences in people in this room in their ADHD symptoms are due to differences in their genes And in the last few studies, it was as high as human height about 91% Twin studies allow us to calculate how much of a trade is due to the rearing environment, and it's zero all 40 twin studies published in the last 20 years have shown that the rearing environment has no influence on this trait Yet the public believes that ADHD originates in bad parenting The twin studies also tell us that there's a small percentage of ADHD that's arising from non-genetic causes And those are those acquired injuries that we talked about earlier And just in case you were wondering, yes, we are discovering genes for ADHD.

We have had more success in this area of psychiatry than with any other disorder that I know of We now know from genome scans published just last year, where we've scanned all 35,000 active human genes for ADHD genes that it's going to be about 20 to 25 sites And out of those 20 to 25 sites, we've nailed down about five to seven of them And here's a few I want you to notice that there's a D in front of the first four genes it means that those genes regulate dopamine in the brain So no surprise, the genes that regulate dopamine are ADHD risk genes And no surprise that drugs that improve dopamine in the brain work for ADHD because those drugs are altering the effects of these genes in the brain which means that psychopharmacology is a form of genetic treatment.

Isn't that fascinating? It's not a band-aid. It's not a cover-up It's not missing the point It's actually helping to manage the underlying genetic problems, if you will, the genetic differences in the brain Now let me take one of these genes and explain it to you because it's kind of cool I won't go through all the genes but bear with me This is a nerve cell that I pulled out of your frontal lobe.

Ouch, I'll bet that hurt And if you look at this nerve cell, when this little baby gets stimulated, an electrical impulse is going to proceed down this nerve cell, and as that impulse reaches the end of the nerve cell, these little packets of chemicals, dopamine, are going to move toward the outside membrane and first And as they burst, they're going to spray dopamine out into that little gap called a synapse And if there's enough dopamine out there, it's gonna cross over and bind to this membrane and it's going to fire the next nerve cell in line.

And that's how your brain works neuroelectrical impulses But the point here is that there's dopamine being squirted outside the nerve cell Now do you see this little baby right here? That's a vacuum cleaner And there are many of them on the outside of this nerve cell because the job of that little pump, excuse me, The job of that little pump is to vacuum up all the dopamine once it's done its job and it's known as the reuptake transporter And one of the genes I showed you, called DAT1, builds and operates that pump If you have a longer version of that gene, you have too many pumps on your nerve cell which means when this nerve cell fires the dopamine gets vacuumed right back up again and it can't do its job.

And it leaves you in a state of too little dopamine Now here's the really cool part People with ADHD have about 30 to 80% more of these vacuum cleaners on their nerve cells in the basal ganglia And the other cool part is You want to know what Ritalin does to the brain or Concerta when you take it? It goes right there and it plugs up the vacuum cleaner. Like a sock at the end of a vacuum hose, methylphenidate stops the transporter from working.

What does that do? Leaves more dopamine outside your nerve cell Methylphenidate is a dopamine reuptake inhibitor By the way, stratera does the same thing, but it does it for norepinephrine little bit for dopamine But nevertheless, we can now link a gene to a problem in the brain and we can link that problem to a drug You shouldn't be surprised to find that that gene is a predictor of who is going to respond to methylphenidate at least in the last three studies that have looked at it which means that sometime in the future When you go into an office, we may take some of your saliva, genotype you, and decide which drug to give you because it's looking like genes will predict your drug response So I would want families to know that because that's probably Five years out, maybe Maybe more, maybe less.

But it's not just genes. Genes can interact with your environment, and that's the purpose of this slide, is to show you very quickly a paper published a year ago by Richard Todd, who died suddenly shortly after publishing this paper, one of our great psychiatric geneticists in St. Louis What you are seeing here is children who were genotyped to see whether or not they had that DAT gene I just mentioned and another risk gene. A plus means you got the gene, a minus means you didn't. Now the top line, you see those Ys and Ns? That's whether or not your mother smoked during her pregnancy with you.

I want you to look all the way to the bottom way over here right side. If you got both of these genes and your mother smoked cigarettes, you are eight times more likely to get this disorder than anybody who had either one of those causes That is a gene by toxin interaction And we have now found the same thing for alcohol So some ADHD is the result of both a genetic predisposition of risk and the fact that the mother may have consumed a toxin during the pregnancy of that child We know that genetic research is the fastest moving area of research right now in ADHD research.

Out of all areas of study, this is the one that is moving so quickly. There are 100 articles a year published on this subject alone What can we expect from this rapidly advancing study? We can expect to do genetic testing to help with diagnosis. We can expect to start subtyping you on the kind of ADHD you probably have. This is going to give us a better idea of what you are at risk for because we are already beginning to label and detect that these genes can be used risk for other disorders, not just ADHD.

For instance, that DAT gene that regulates that transporter is a predictor of nicotine addiction We also know that these genes are going to interact with each other and with toxins in the environment So that's going to help explain why some people got ADHD And as you see here, it may help in predicting drug response. And notice we now have a paper just published within the last year that shows that whether or not your child responds to behavior modification is partly related to some of these genes. Sensitivity to psychological treatment may be in part genetically mediated.

Expect to see new drugs being developed just for these genes And new psychosocial treatments may be developed for certain genetic subtypes. How cool is that? I would want families, therefore, to leave my office understanding that ADHD does not arise out of the family or from social causes, and especially to understand that these things that are very popular in the media and among many uninformed parents are not are not causes of ADHD for the most part Not the least of which is television. TV and video game playing are not causing short attention spans. If I hear this again in the media, I'm going to throw up. This is now taken as gospel.

It is mere folklore. There is no evidence that human attention spans have changed at all What is changing? is the amount of media you can distract yourself with if you so choose. But it doesn't mean that this is causing a short attention span.

You've just got more media to pay attention to, okay? And of course, if you are easily distracted and you don't like to read for pleasure or sustain your attention to things, you have a lot of choices out there So we do know that people with ADHD watch television more, play video games more, use the internet more, talk on their cell phones more, text message and Twitter more than other people do That doesn't mean these things cause their ADHD. It's the other way around. ADHD leads you to select these as leisure activities because they're so engaging.

We know that food additives don't cause this disorder, but about one in 20 ADHD children could be exacerbated by a little bit of these things in their diet but it's a minor, trivial, scientific finding. You don't need to go changing your child's diet as a means of dealing with ADHD. And by the way, that includes supplements like omega-3s which were recently found to benefit less than 25% of ADHD, only the SCT inattentive type appeared to benefit. It was modest, it was trivial, but it was kind of interesting.

But ADHD combined type did not appear to benefit much from fish oil That's a nice randomized trial published in Sweden just about two months ago. And of course we know that child rearing has nothing to do with it.

So I would want the family to understand, here is a pie chart of the causes of ADHD 65 percent, roughly, genetic All the rest are biohazards that can provide or produce brain injuries And there is no social factor on that list Now, viewing ADHD as this neurogenetic I would want you and families who I counsel to take a moment to reflect on the importance to understand, not the least of which is this one This is ADHD writ large It's always now ADHD is to summarize it in a single phrase Time blindness People with ADHD cannot deal with time And that includes looking back to look ahead to get ready for what's coming at you So the individual with ADHD is kind of living in the now.

And wherever the now goes, they are being pulled along by the knowns, wherever it goes. I'll give you an example from our adults clinic. It's rather funny, but it wasn't to his wife. This couple came into our office in Massachusetts once, and she said, let me tell you what it's like living with this guy because it's like having a fourth child actually. This is what happened last weekend She says, if you can't do something about this, I'm leaving him Here's what happened. He went out to mow the yard He wheeled the lawnmower out of the garage and the tank was empty.

So he reached for the fuel can, it was empty too. So he threw it in the back of the Ford Explorer and headed down to the little quickie mart And while he was filling up the gas can his buddy pulls in in his Ford Explorer and says, you know, it's opening day on the trout stream What do you say we go fish a little bit? And so the guy hops in his buddy's Explorer and they go fly fishing. And they are out for six hours. And then they get thirsty and decide to stop off at a pub for a beer. So now they're at the little local tavern.

It's a true story, by the way, because within an hour, the state police had found his car still running in an open gas can at the quickie And he finally wandered home at four o'clock in the afternoon.

Do you see what happens? Doesn't matter what your plans were, what your goals were, the now is more compelling than the information you're holding in mind and you will get pulled along by the now You are time blind Because if we had to summarize In a single sentence, what is the purpose of the frontal lobe to humans? It is to organize your behavior across time in anticipation of what is coming at you future So, ADHD creates a blindness to time, or technically, to be more accurate a nearsightedness to the future We still have the evidence I can only be eloquent once. This is extemporaneous. I'm not. Okay, ADHD.

Right is at its heart a blindness to time, or technically, to be exact, it is a nearsightedness to the future. Just as people who are nearsighted can only read things close at hand, People with ADHD can only deal with things near in time The further out the event lies the less they are capable of dealing with it.

And this is why everything is left to the last minute because they only deal with last minutes That's all they perceive, that's all they deal with, that's all they organize to And so their life is a series of one crisis after another, all of which were avoidable because people prepared And they didn't They weren't ready on time, in time, over time with what they needed at that time Note the word time. So ADHD is destroying the timing and timeliness of human behavior. That is a very important thing for parents to understand.

Because while a three-year-old does not have to have a sense of time, A 30-year-old does And one of the most devastating deficits in adult life that ADHD produces is a disruption in the fabric of time they can't cope with it as well as others Now, this ability to organize across time comes with the capacity to build pyramids of behavior, from little behaviors to big ones to the bigger behaviors above them, to the bigger goals above them All human behavior can be organized into a hierarchy.

Think about planning a wedding Can you imagine the hierarchy you would have to create? the decision trees, and when they would have to be done, and when you would have to book the church and get the minister and get the flowers and book the reception hall And all of those come with little subroutines, like picking up a telephone and calling your minister, right? It's the frontal lobe that allows you to organize all of those toward the single overarching purpose The Wedding and that's what ADHD destroys People with ADHD cannot hierarchically organize behavior.

And so they are accustomed to dealing with behaviors in little fits and starts But they can't glue those together as well as others to create the bigger goal to the bigger goal, all the way up And that's why you see a short attention span. It's not really a short attention span. It's the inability to organize behavior across time into a hierarchy. The ability to look ahead is called intention So ADHD is actually IDD It's intention deficit disorder because it doesn't matter what your intentions are you're not going to do them. So, oh, you can head out the door for school in the morning and promise your mother that you will not be put in time out again.

You really will get it right today You will behave yourself, you will not fight with the other kids, you will finish your work, and you mean it sincerely But within an hour, your mother's getting the usual call that you're in timeout and that you're disruptive and they need to come and get you. Notice what happens. Your intentions are not the problem. And it's not insincerity It's the inability to organize around those intentions So ADD is really IDD Now, I want you to understand something. Your brain can be split into two pieces.

The back part is where you acquire knowledge The front part is where you use it The back part is knowledge, the front part is performance ADHD like a meat cleaver just split your brain in half So it doesn't matter what you know you won't use it You have what we call in psychology a performance disorder Performance disorders have nothing to do with skill. You have all the skills other people your age possess but you can't use them Because you see, it's the executive system where the rubber meets the road where what you know gets applied in every day what you do And ADHD is a disorder of doing what you know.

It is not a disorder of knowing what to do And that is a very important thing I want families to understand as well your child unless they were raised in a zoo or in a very impoverished area or were adopted out of some far-fetched, war-torn, undeveloped country has all the information and knowledge that the other kids their age have What they can't do is use it It is the application of what you know that this disorder robs you of.

So you can be the smartest person on the planet, and you're still going to do some pretty stupid things Because it's not what you know It's doing it So, I would want parents to understand that that is a very profound disturbance in a person's behavior but it arises out of neurology and genetics. And out of this is going to come a very important view of what to do about this disorder Bye! The first thing this is going to mean you is to stop teaching so many damn skills Because you're approaching this child as if he's stupid, right? Oh, he doesn't have any friends. I guess he doesn't know social skills.

So we'll take him down to the local clinic and we'll enroll him in a 12-week social skills camp, about which we'll probably pay $50 to $100 a session. Or we'll send him to the Upper Peninsula of Michigan, where there's a nice summer social skills camp that was advertised in Chad's Attention magazine I think there is. It's probably a very nice camp. I don't mean to belittle it. I'm just telling you it will do no good. Right? Right. Right. Right. Right. Right. Right. Well, now let's understand something. I might want to send a child to camp just to have fun.

Right? It's part of the quality of life. Go! Have a nice summer But if I'm sending you to camp with the belief that you're going to come back a person with better social skills, you are sadly mistaken So we have got to stop putting all the eggs in the skill training basket because that's not where the problem is We have got to spend more time changing the point of performance The point of performance is where you should be using what you know And you're not And the only way to treat a performance disorder is to change that point.

This means that all treatment, if it is going to work at all, must be at the point of performance The place in your life where you're not using what you already know And if the intervention isn't done there, it's useless That has been a major finding of the last decade.

The only treatments that work are treatments that modify those natural points in the environment where the problems are occurring and if those aren't modified nothing done away from that site We'll do anything So you can do pull-out services, you can go to summer or to social skills camps, you can go to special ed, you can come and see me for once a week for psychotherapy and everything I just said will have no generalization or maintenance. Won't go anywhere. Won't even leave this room.

Howard Abacoff tells a beautiful story of the social skills group he ran, and on the day they covered anger management and sharing He opened the door to the room and there was a fist fight in the hall by the elevator over who was going to push the button. So much for your anger management, right? You see what happens? You were focusing on knowledge. Oh, let me teach you how to share and cooperate And you missed the point This is not information deficit disorder This is performance deficit disorder So you gotta change those points of performance.

If he has no friends on the playground, you're gonna have to do something at that school If you got trouble with homework, it's the kitchen table, honey. It's not my office We need to rearrange where the homework is being done to help them show what they know. As I've already said, this point of view also then makes us look very differently at psychopharmacology as a form of neurogenetic treatment Now, everything I have just said could be used by any parent to come up to me and say, My child got thrown out of school yesterday for some misbehavior.

Would you please go to school and get him reinstated? He should not be held accountable for these consequences. Right. So, thank you Because after all, didn't you just say it's a neurogenetic disorder? So let me help you understand something about what I've just said ADHD does not cause a problem with consequences The problem is with time It was the delay to the consequence that disabled you Which means that I'm gonna do the opposite of what this mother is asking increase accountability not decrease it increase the frequency, immediacy, the salience, and the timing of consequences People with ADHD need more accountability, not no accountability.

In fact, this view of ADHD as an executive disorder would tell you that if you argue for no accountability, you will make this disorder worse Not better because the problem is the delay and all natural consequences of any importance are delayed What does that mean? We are going to have to use behavioral treatments. The BMOD programs, the tokens, the charts, the cards, the smurf stickers, whatever What is their purpose? Their purpose is not to teach.

That is a misnomer, if you will Their purpose is to sprinkle artificial consequences into these delays in the natural environment in order to increase your accountability So they're not teaching anything they are making up for the accountability deficit disorder B-Mod does not teach anything to ADHD children, really What it does is improve the motivation to show what you know by making you more accountable, more often around you you have less ADHD By excusing you from the consequences, you'll be more ADHD. So I want you to understand something. There are two reasons why we would tell you as a family to do behavior modification. One is instructional This is why we teach families of autistic and mentally retarded children behavior modification.

To teach their children things they don't know But the second purpose you would do B mod 4 has nothing to do with instruction It's motivational. To make up for the motivation deficit disorder that this disorder produces And so if you do BMOD for its motivational value You can't stop it Because if you pull it, you've pulled the motivation If you do BMOD for its instructional purpose You can pull it Because once they've acquired the skill, they'll use the skill and you don't have to worry about it anymore.

Now, do you see a contrast here? Most parents and nearly all teachers I deal with, they're not going to be able to do that believe that BMOD is for instructional value That's why we do it for ADHD, which is why whenever you go into a school and you try to teach a teacher to set up a token system, the first question out of his mouth is how long do I have to do this? when will he internalize the program? And my answer is, Never As long as he's in your class, you will have to arrange artificial consequences to replace the delayed ones.

And if you don't do that, he will not work for you So I want you to think about token systems and star charts and all behavior modification as being equivalent to a ramp that comes into this building That ramp is there to make people who are physically disabled less motorically impaired they can get into the building, in their wheelchairs, or whatever other devices they're using But would you ever say to such a person, after 30 days of entering this building successfully using the ramp, you know the punchline, right? Can I take the ramp away? Have they internalized the ramp? Well, of course not.

The ramp was never for teaching All right, the ramp is a prosthesis A prosthesis is an artificial means of reducing the disabling consequences of your disorder It is not to train you up into anything. No amount of using a ramp is going to take the ramp away And no amount of B mod is going to take the B mod away These individuals will always need more frequent consequences around them than will other people in order to perform at the same level.

It's just a general corollary of ADHD So, what else have we learned about ADHD? Well, if all treatment is at that point of performance, and if at that point of performance I'm trying to arrange a prosthesis, a prosthetic environment to reduce the impairment from the disability then it means that the caregivers are the most important people in the treatment plan the parents and the teachers It is their compassion for disabled people and their willingness to make these prosthetic accommodations that is the heart of any successful intervention and absent that compassion No amount of quality in a good professional or therapist is going to change that You have to make those people stakeholders. You've got to get them invested.

And if they're not, you're in trouble.

It doesn't matter how good a clinician you are So it's best to look at ADHD, I would be telling these families in my office, like we look at diabetes largely a chronic disorder and our goal is to manage it to create a reduction in the symptoms The purpose of which is the avoidance of secondary harm We do not treat diabetes to get rid of it We treat it to prevent what happens to you if you don't manage your diabetes, because you will go blind and your heart muscle atrophy and you are at risk for sudden death and you will get gangrene And you may have your toes or fingers or other appendages eventually amputated if we do not manage your insulin levels That is what we try to prevent But no amount of treating diabetes is ever designed to get rid of the diabetes And I think ADHD is a very good analogy I think we manage ADHD to prevent the secondary harms, which I'm about to show you We don't manage ADHD to get rid of it manage it so that you don't experience those more heinous consequences So, by changing the environment, you're going to be able to help compensate for the impaired executive abilities.

Now, the ADHD view of ADHD, the attention view, does not tell you what to do Does not one wit does it guide me? If you tell me somebody is inattentive, I don't know what to do for them. What, more coffee, as I said? All right. But if you tell me somebody has an executive disorder, I will give you five things to do immediately at any point in performance Goodness, it's 3. 30.

Can I give you a break right after this one? Okay Number one Your child cannot stop and hold things in mind So don't make them you need to use external physical forms of information which means sticky notes, signs, symbols, charts, cues, reminders The issue here is not the what, it's the why you must find a substitute for working memory And that means something external. The information, whatever it is that is key for you to remember right here, right now, needs to be outside of your brain in the visual field You have got to externalize is the phrase for that the information that other people are holding in mind. It's what we are doing after age 55 and women in perimenopause.

We are using a lot of sticky notes, let me tell you. Because I'm 59 years old and I already have a little ADHD, working memory disorder, as do most women, by the way By the way, it hits women harder than men but it hits us both Nevertheless, we're all running around with lists.

What was I doing? My wife even has a digital memory recorder in her car so that when she's out and she has to remember something, she dictates it in there so she can listen back and remember what the heck she was supposed to buy at the shopping center you You see what we're all doing? Making up for a working memory deficit you need to do the same thing with ADHD If you're an adult with ADHD, you should not be going anywhere without a paper journal in your pocket with a pen Because anything you agree to do, or anything others ask you to do, is to be immediately written in that journal.

And that journal is welded to your body That is your working memory. Use it. And by the way, we find journals are better than digital devices because they lose the devices and they don't remember to turn them on and they don't remember to dictate into them So as good as those things may sound and as high tech as they are, the good old paper and pencil notebook seems to do the job. And if I were you, I would even have it on a chain like a motorcycle gang member has his wallet. It is there from sunup to sundown.

Man, when you put your pants on, that is in it all the time and now you have a working memory You have no internal clock So if anything involves time, there must be a timer There must be something physical outside of you that signals the passage of time. For young children, cooking timers are great, but there are various other devices, including watches that beep every five minutes and vibrators that you can buy at the addwarehouse. com that have digital timers built in and you can set them to just vibrate in your pocket every so often.

I don't care what the stimulus is This is the why people, not the what The why is you have no sense of time So if I give you something that involves time, I have got to give you a timer. And that's why I'm here And if this extends more than just a few minutes to a half hour You are going to need a day planner, a palm pilot, or some other means of keeping track of time.

A week at a glance calendar is not a bad thing either but you are going to become timer and calendar dependent, addicted so that you can organize your life as well as other people who don't need to rely on those things so much you cannot see the future coming at you. So if there is something you've agreed to do over time, if this child has a book report or a science project, you are gonna break that into baby steps and do a piece a day You are not going to point at the future and keep harping about summer reading.

Have you done your summer reading? We've got that book report that's due next week, have you done that? No, we are gonna take the book report and you are going to read three pages today. You are going to write four sentences today, and I will give you 15 tokens right now. And that's how we're gonna get this done We are going to break the future into pieces and do a piece a day and stop pointing at the future, because you can't organize to the future That is your disability.

That's like going on to an inpatient unit at the psychiatric hospital and saying, God, these people hallucinate around here What's going on? It's an inpatient unit, they're schizophrenics. What did you think, right? You should not be shocked that you have to break things down for people who have a time management disorder And so you should do it for people with ADHD as well. Break the future into pieces. By the way, what does ERO mean on this? It means that the future comes at you in three pieces the events that are coming toward you the responses you prepare and the consequences, the outcomes of what you're doing E-R-O.

So here's the lesson I would want this family to understand If those E's and R's and O's are kept close together, we can do it you don't need a frontal lobe and ADHD people can do them. That's a video game but the minute you stretch these things apart with time like a book report You've got to read this book. Your report's due in 30 days. It'll take a week to grade all the papers. I just put a month between the E and the R and a week between the R and the O And if you have ADHD, you're disabled Big time So the solution is to get the Es, Rs, and Os back together.

And that means baby steps. Little e-r-o bridges across time And that's how you would do a future assignment Now, how are we going to deal with the fourth executive function deficit, the emotional motivational one? It means all motivation is external. We already talked about this which means I am going to have to have something in it for you if you are going to persist So stop whining, stop complaining why you have to offer something for this child to work The reason you don't offer it to other children is they have internal motivation.

ADHD children do not So don't worry that by paying them tokens for doing their reading or their assignment, you're somehow going to pervert a sense of doing things for their own reward or value being a good citizen for the sake of being a good citizen. That is not going to work for ADHD. The ADHD child is Donald Trump incarnate and there better be a deal. And if there is no deal, it ain't getting done.

So to borrow a phrase from Stephen Covey, please think, win, and win win A win for them, not just a win for you And that means you are going to have to drop in the points, the tokens, the privileges, the sex, the drugs, the money, and the car. My medication's running off. I think The last executive function, which is mental play, it's the ability to manipulate the contents of your mind in creative ways to invent multiple possibilities. Very hard for these people. This is why they can't do mental arithmetic as well as others.

It's why they can't do digits and backward as well as others That's why they have trouble playing the little musical game Simon working memory, but if you can't hold things in working memory, then you can't manipulate your working memory And that's where the source of planning and problem solving are coming from. So what do we do? Well, we're gonna take the same word we did before externalize. We're going to make problem solving manual physical you get to do it with your hands. So let's take math problems. I'm going to give you a bunch of marbles a number line Anabacus or a calculator, but the first three would suffice.

Right you're going to do math with your hands, the way it originally was done I'm not going to ask you to do arithmetic in your head. You're going to find that to be difficult. You need a crutch. You need an external prosthesis to help you with your math. Now, what if this is a verbal problem or task, like you've gotta write a story or an essay or something? I'm gonna give you a stack of three by five file cards And I want you to sit down and put your mind on dump I want you to think of any idea you can come up with that has to do with this subject.

Go, I want a thought per card I don't care what order, I don't care what sequence, just let your mind run wild but just give me a thought a card Now I'm going to take your cards and reorganize them And now we've got him physical. And now we can create the story and the plot line. And if you do this on a laptop computer in Word You can even move it around and spell check and cut and paste and do all that neat stuff because it's now external. Your ideas have become physical. And that's the secret here Make the mental information physical in some way and then they might be able to do it.

This may explain why more people with ADHD wind up in the trades than in any other professions I used to think it was because the trades don't require as much advanced education I now think it's probably also the fact that it's manual Whether you're a carpenter, a plumber, a landscaper, a bricklayer, a tuner, electrician, tuner of pianos I meant to say, or others you are doing something manual and that may matter.

We'll see Lastly, ADHD rarely occurs alone ADHD children are at risk for all of these other disorders In fact, 80% of ADHD children and adults will have one of these other disorders, and 50% will have at least two of these other disorders So seeing ADHD by itself is very rare Seeing ADHD link up with a few other disorders is not rare. It's very common And so I would want families to understand that we may have to treat other disorders, not just the ADHD. The ADHD may be one problem, and it may be the biggest, most impairing problem but it's not the only problem that we may have to deal with.

And on that note, we are going to give you a 10 minute break. You will be called back at 10 minutes to four because I got 15 other ideas I wanna share with you. Oh. Thank you. I apologize. Thank you Thank you so much untreated ADHD is likely to have associated with it over time And this is from my own longitudinal study and others First of all, school is the major area of impairment, but we all know that. They're more likely to be held back in school. A third of them quit high school without finishing.

Only 5% to 10% ever finish college So undereducation is a classic ADHD impairment But that, of course, is going to lead to problems in the workplace And you can see the ones that we've identified here And it's also going to lead to problems in driving, because we know the single biggest cause of auto accidents in the North American population is in-vehicle distraction And this is a distractibility disorder So no surprise, they're going to have problems.

But they have problems at all levels of driving, as you see here more speeding tickets, more car accidents, multiple accidents, worse accidents, and as a result they're going to have their licenses suspended three times more often than other people So driving becomes a major problem.

In fact, as has been said, there is no disorder that interferes with driving to the degree that ADHD does So this is a major area of impairment, which is why your Canadian Pediatric Association has now recommended that if pediatricians see a teenager who's about to start driving and they have ADHD that it's at least moderate in severity you need to medicate them while they drive I would say that that should be the case for nearly all clinically referred people with ADHD Because if they're clinically referred, they probably at least have it to a moderate to a severe degree Why is that? Because you can kill yourself and you can kill other people as well with a motor vehicle.

And we don't want to see that happening Now in addition to those, there are some other areas of impairment, not the least of which is managing money. As they move away from home, as they get jobs, as they get credit, as they borrow money, as they take out car loans we start to see them having troubles paying their bills, paying them on time, so that they get their utilities turned off, their cars repossessed, their credit rating is terrible, because you've given a very impulsive person credit.

Is there a bill for that? No Boy, could we use that these days, huh? Everybody working for AIG would go on this But this is an area that very few people took a look at. But, duh, I mean, it makes perfect sense when you phrase it as a disorder of self-control given a credit card And now we can understand what's going to happen with the credit problems So obviously they need more accountability in their financial management Social problems are going to continue into adulthood for many, though not for all of them.

They often, as adults, describe themselves as having trouble sustaining long-term relationships, particularly dating and marital relationships or partnering with people And we will see that they do experience divorce at a higher rate than other people do because of these difficulties. An area now that has been studied more in detail is the area of sexuality. We do not find more sexual disorders. So pedophilia, transvestism, or other difficulties are not more common in this population.

What we do find, as you would guess, us knowing an impulsive person is greater risky sexual activity starting to have intercourse a year earlier than other teenagers, having more partners because they don't stay in dating relationships as long, not using contraception because they're so impulsive all of which leads to a tenfold increase in teenage pregnancy. We now know, in fact, there is no better predictor of adolescent pregnancies than ADHD In my study, 32% of the boys had fathered a child by 19. 68% of the girls had been pregnant at least once before 19 years of age. So, this is a disorder that predisposes to becoming a parent very young.

And by the way, we saw the same thing in the parents of these kids as well and that's because their parents have ADHD also. ADHD in adults leads to earlier parenthood than the general population would be experiencing And then of course, notice a four-fold increase in sexually transmitted disease So we have a group of individuals who, if not treated, are going to be experiencing impairments in every major life activity we have studied.

There is no domain of life free of the influence of ADHD that we have yet identified which is why we argue now for longer-term treatment across the week, across the year, and especially through adolescence Because most children, if they're on medication, it's for three years or less And if they're in treatment programs, it's only for a few years or less. And what we have found in these studies is that childhood-only treatment was useless useless in terms of changing the life course of these individuals.

Now to understand why these disorders, why these impairments that is, would continue into adulthood, we need to go back and understand that it's a disorder of self-regulation and it's a quantitative deficit, so that begs the question, how far behind is this child? And so the rule that I have taught for years in our clinics to families, and it remains a very good rule of thumb is the average ADHD child is 30% behind their age Some are even more. But on average, across all ADHD children, it looks to be about 30%. So here's what I want parents to do.

If your child is 10, he has the self-control of a seven-year-old That is how long he can persist. That is how long he can remember. That is how long he can go without supervision His ability to self-organize is that of a seven-year-old. Now, what would you do for a seven-year-old? How would we arrange homework? What else would we be doing around chores, around social functioning, around independence from parents? you wouldn't be doing as much as you would with a 10-year-old you would not allow as much responsibility, as much freedom, as much independence So I want parents to be lowering their expectations to the child's executive age What is his self-regulatory age? It's 30% younger.

All right, that's what you can expect. And if you're expecting more than that, then you're not getting it You're my problem because you're causing the conflict. You are like a parent of a dyslexic child demanding normal reading You are like the parent of a mildly retarded child demanding normal self-sufficiency, normal cognitive development. You're my problem, because you just don't get it So I want you to get it. It's a 30% lag That's where they're at. That's what you can expect.

If you're asking for more, you're going to have to do something to rearrange that environment to allow them to show what they know But if you don't do anything, they're going to be about 30% behind So what does that mean at 16 about giving kids a license? Are you out of your mind? You just gave an 11-year-old a motor vehicle.

And you're shocked to see the driving consequences You may have an 18-year-old who's one of the few that's going to go on to college He's 12 That's his executive age How would you have to design a campus? if 12-year-olds were showing up to go to school Those exactly are the accommodations you have got to make on that campus for this person Pretend they're 12 more handholding, more accountability, more reporting to student services You're going to get more curriculum materials. You're going to study in groups with older, more competent students. You're going to be in a substance-free dorm.

And you are going to be accountable to student services four times a day for the work you're doing In other words, we're gonna treat you like you're 12 and then you might just get through But what do we do now? We send you off, you fail the first semester, and everybody wrings their hands of, oh, what are we going to do? We're going to have to change the campus. We're going to have to change the environment to suit the executive level not the chronological level So you need to understand the 30% rule because it applies to everything I have a 14-year-old daughter with ADHD.

Should she be allowed to babysit? Are you crazy? Right? This is a nine-year-old being given care of an infant? No way. I don't care if she finished the Red Cross babysitting course. I don't care if she's got a certificate. We don't let nine-year-olds attend three-month-old babies unsupervised And that is her executive age You think this is hypothetical? We have legal cases of people even into their late teens and twenties who have killed babies out of anger, out of impatience, out of immaturity, out of not knowing what to do when the baby got upset.

And then their emotion comes to the forefront So we don't want to go there So you should be looking at all of these avenues of independence and applying the 30% rule to them and that's what you allow. And if you are going to give them more, you better be doing something to see that they can handle it Okay, we want you as a parent to understand that every treatment plan has to have these four components or it's not going to work Component number one, you've got to get a good evaluation. You have got to see an appropriate, knowledgeable professional.

It doesn't matter whether it's a developmental pediatrician, a child psychiatrist, a child psychologist, or a behavioral neurologist, as long as they are well-trained and knowledgeable about ADHD. That's the trick Thank you It's not the degree It's the knowledge, it's the training, it's the experience. Do they see lots of ADHD kids and families or adults? So we need an evaluation because 80% of these people have another disorder and that's gonna need to be treated as well Next Families need to educate themselves. We'll talk more about that But you need to become an expert about ADHD or you're not going to know how to deal with it.

Attending this afternoon has been a big step in that direction Third, you need to understand that medication is the most effective thing we have. And that doesn't matter to me whether you like that or not. That is a statement of fact We have no more effective interventions than these medications, which is why in the last decade we have moved them up in our priority of using them. It used to be that we would try everything else under the sun first and only if they failed go to medication. Well, guess what? 80% of them failed and we went to medication anyway.

And we should have started with it to begin with because it would have made them more minimal and more susceptible to the other psychosocial educational programs we were trying to do So don't be surprised to learn that up to 80% of ADHD children will be on medication at some time in their developmental period, whether that is childhood or adolescence. Because there are times and places where you cannot institute a psychosocial treatment. If your child is driving home from the homecoming last night, later which was over at the Delta Hotel, by the way. I checked in and there's a prom going on.

You can't be there handing out tokens for following the speed limit. You know, this is idiotic to think that behavioral interventions are as good as medications. They're not where they're done, when they're done, they're good. But there are places where they can't be done And now what do we do? The medications fill those gaps So that's why we use them and that's why you're seeing medication on the increase in both of our countries. And it is completely rational to do so then we make accommodations That's what I meant by altering the points of performance using those five strategies we talked about, externalizing information.

You need to create prosthetic devices in these places to help them show what they know So then as a parent, now that you know ADHD and you know that it's a more profound and a more impairing disorder than we once thought, what can you do? I want you to take three roles and you can read about these in my book, Taking Charge of ADHD. The first role every parent should play is to become a scientific parent, which means make yourself an expert I want you knowing as much as the professionals know So you should be reading widely because truth is an assembled thing. It doesn't come from a single website or source.

It comes from integrating across those and seeing the reliable information that keeps showing up across the various sources that you're reading So whether you go to chad. org or add. org or caddic. org or the other websites Read, learn, become an expert, know as much as you can. Just like a family of a diabetic child needs to know diabetes inside and out if they're gonna appropriately cope with and compensate for that child's diabetes And then, just like a scientist, you're going to have to experiment. There are hundreds of things that you can do, but they don't all work for every child So we have to test, revise, test, revise. Try it.

Does it work? If it doesn't, let's move on to something else So there's a test revise process about raising an ADHD child. You're not going to get it perfect out of the gate. And what worked for one parent may not work for your child. And somebody may be unconcerned about your child's going to need Adderall or Vyvanse or Stratera And the same dose that worked for one may not work for the other. It is a process of experimenting and letting your child show you which of these things may work for them So be a experimenter.

I tell that because parents come in and they try the token system and it didn't work and they try time out And expecting that the first thing out of the gate is going to be successful. And it isn't always so You gotta keep trying. And then I want you to become very skeptical. There is a lot of junk knowledge out there, especially on the internet. You type ADHD into Google, which I did this morning, 14 million replies There is no way a parent can search that for the diamond in the dung heap So I want you to become very skeptical.

If you are not hearing this information reliably across different sources, it probably isn't true And if it sounds too good to be true, just like financial planning, it probably is. So be careful out there. There are magnetic mattresses, there's copper bracelets, there's ginkgo biloba, there's omega-3-6s, there's antioxidants like pycnogenol, there's so much junk out there, there's a classic clinic in Las Vegas that will diagnose your whole family and give you chips to spend at the casino. You know, maybe that works. I don't know, right? But you get the point, all right? There is so much trash out there that it's hard to sort it out.

So that's why you really need to have your skeptic hat on whenever you're reading anything and you're looking for reliable information across sources and then you will filter out the gems The next role, you need to become an executive parent. You need to stop whining, suck it up, man up, and own this disorder in this child. This is the hardest thing for families to do. They learn about it, they read it, but they don't necessarily own it.

There is this sort of, if you will, reticence that they have in terms of this internally that I see from time to time, where they always hold out this hope that there's some silver bullet out there, usually on the internet, that if they just tried that, all the problems would be solved, we could give this up, he'd be normal, and let's get on with life And I wish there was the silver bullet, but there isn't So we tell this to ADHD adults as well. It's one thing to know ADHD. It's another thing to own your ADHD and to make it a part of who you are It's not all of who you are.

You may be a gifted artist, you may be a comedian, you may be a scientist, you may be a physician. None of that has to do with ADHD ADHD predisposes to no gift But you do have other gifts and other talents at which you are good at So I want you to embrace ADHD as part of who you are, but not all of who you are ADHD is a small set of traits out of the more than 400 that you were blessed with So you may be good at lots of other things. Let's find those other things because they're gonna have to compensate for what your ADHD is dragging down.

But don't ever attribute those other successful enterprises to your ADHD, because it just ain't so. This is no gift But it doesn't mean you don't have other talents that we could use to compensate for it. Whether you're a good athlete, whether you're Michael Phelps, whether you're a good comedian, whether you're Ty Pennington on America's Extreme Home Makeover, who loves to tear down houses since he was a kid, and now he does it for a living All of these are ADHD adults But their giftedness is not due to their ADHD.

It was something they found that they did well, that could compensate for the problems that their ADHD had caused So becoming an executive parent, like becoming an executive adult with ADHD, means part of it is, I own the disorder My child has this disorder, because until you own it, you will not advocate for this child And you have got to get out there and advocate and not let other people take charge of your child. That's why I called my book Taking Charge of ADHD.

Because too many times I went to school conferences and I saw parents sit intimidated by the degrees sitting around the table and saying nothing about what was being said in that meeting And I have to remind parents, these people work for you. You are the taxpayer. This is your child. You should be running this meeting. I want you coming in with a pad and a tape player, and I want you turning it on, and I want you saying to people, I'm not going to be able to take all the notes I want. I'm going to record this meeting. Now, let's talk about my son.

Let's start talking about him with you. You're his homeroom teacher. What do you think? What's going on here? If you have to, run the damn meeting. And if somebody says something you don't understand, like your child's Woodcock Johnson psychoeducational IQ was, you are going to stop this meeting cold in its tracks. I don't know what you're talking about Because you're going to see a lot of jargon tossed around by school professionals, part of it's just showing off So stop it, right? If you don't understand it, you advocate.

And you can't advocate if you don't know what they're talking about and then the final decisions are always yours whatever the list of recommendations are, because sometimes the recommendations don't fit your child This is just a list of recommendations that apply to ADHD plain vanilla, and you may not have plain vanilla So you're going to have to look at those. You know your child better than anybody else. And you will pick and choose from those the ones you believe are most suitable to your family, to your child, to your values, and so on but you run the meeting and you don't sign off on anything that you are not comfortable with.

I love parents who come in and give me grief I do not like parents who come in and sit like a bunch of milquetoast sitting in an office and just listening, listening, listening and not asking questions and not advocating and not telling me, I don't think that's going to work. His grandparents are not going to buy Concerta. They're going to take us to court for child abuse. You got to help me with that. That's a true story and that's what I'm going to do That comes from my nephew So consequently, families need to speak up.

How do I know that your grandparents are resistant to medication and that they will make your life miserable if you don't tell me? Okay, now I can tell you how to help the grandparents But you see if the parent doesn't talk up, I don't know I can't help you cope with that Rule number two, advocate.

Number three, if you haven't read Covey's The Seven Habits of Highly Effective People, you better In fact, the better book is The Seven Habits of Highly Effective Families Because we have found that more than any other families, families raising disabled children really need to learn and utilize these Covey has at the back of the book a diagram that looks like an hourglass that has all seven principles built into these two upside-down triangles photocopy it, and tape it to your bathroom mirror When you are putting on your makeup or shaving in the morning, I want those seven habits in the corner of your visual field That is your morning reminder to try to get it right I do that, you should do that, and I didn't raise ADHD children, but these are very good principles for interpersonal relationships, and especially if you have a disabled child.

So if you're not familiar with it, these are the seven principles. You can read more about them Now, once you have adopted these three roles, there is another role I would like you to assume. And this, I think, just paints the whole picture. This is sort of the background canvas on which you paint the rest of this portrait You need to understand something that parents these days have long since forgot and are going to have to relearn again.

Your grandparents knew this, but today's generation of parents doesn't seem to and that is you do not get to design your children Nature would never have permitted that to happen Evolution would not have allowed a generation of a species to be so influenced by the previous generation.

It hasn't happened and it doesn't happen, and it especially doesn't happen in children You do not design your children And yet we have the Mozart effect, the belief that if I play classical music to my uterus when I'm pregnant, I'm going to have a genius The fact that if I can just put enough crib toys over his crib, he is going to have all these neurons exploding with synapses and be a brilliant mathematician You don't get that degree of power Does that mean stimulation doesn't matter? No, it means a stimulation environment is better than a deprived environment. But it doesn't mean that the more stimulation you add into the environment, the better it gets.

It's a threshold There is enough stimulation that every normal brain needs to develop. And once you're past that, which 98% of you are, The rest of it is out of your hands But this idea that if a little bit is good, a ton of it must be better is a uniquely North American perspective Believe me, the French don't look as kindly on their children as we do That's another story for another day.

That's another story for another day So, what we have learned in the last 20 years of research in neuroimaging, behavior genetics, developmental psychology, neuropsychology can be boiled down to this phrase Your child is born with more than 400 psychological traits that will emerge as they mature and they have nothing to do with you So the idea that you are going to engineer personalities and IQ and academic achievement skills and all these other things just isn't true Your child is not a blank slate on which you get to write If you would like to read more about this, please read Steven Pinker's book, The Blank Slate which is a review of all of this information for parents and why it isn't true The better view is that your child is a genetic mosaic of your extended family which means this is a unique combination of the traits that run in your family line I like the shepherd view.

You are a shepherd. You don't design the sheep The engineering view makes you responsible for everything everything that goes right and everything that goes wrong. This is why parents come to us with such guilt, more guilt than we've ever seen in prior generations because parents today believe that it's all about them and what they do, and if they don't get it right, or if their child has a disability, they've done something wrong when in fact the opposite is true This has nothing to do with your particular brand of parenting So I would rather that you stop thinking yourself as an engineer and step back and say, I am a shepherd to a unique individual Shepherds are powerful people.

They pick the pastures in which the sheep will graze and develop and grow. They determine whether they're appropriately nourished. They determine whether they're protected from harm The environment is important, but it doesn't design the sheep. No shepherd is going to turn a sheep into a dog. Ain't going to happen. And yet that is what we see parents trying to do all the time, and especially parents of children with disabilities So step back and view yourself as the shepherd to this disabled youngster and you get to design the pasture.

And that's very important, but you don't engineer the sheep Now that comes with it a profoundly freeing view of parenting Because what it means is, although it's important to be a shepherd Recognizing that this is a unique individual before you allows you to enjoy the show, right? So open a bottle of Chardonnay, kick off your slippers, sit back and watch what takes place, right? Because you don't get to determine this. So enjoy it. It doesn't last all that long anyway. They're gone before you know it But if you think that what you did in your house is going to shape the life course of this individual, you are sadly mistaken This is a unique individual.

Let them grow, let them prosper. Please design appropriate environments around them but you don't get to design them As Judy Harris said in 1996 in the first book on this subject written for lay people The book is called The Nurture Assumption. As she said, you had more to do with your child's life by where you chose to live than by anything you will ever do inside that home short of abuse, neglect, or malnutrition The rest of it is just trivial variation It's where you live. Why? Because out-of-home influences are more powerful in shaping the life course of your child than in-home influences are And those out-of-home influences are peer groups other adults neighborhoods resources Schools and the larger community that you made available to this child.

That is how you shape your child's life course The second biggest influence is also out of your hands, and that's genetics and you don't get to determine that But if you think parenting is so influential, let me give you two findings that have been replicated many times When we follow up twins, we are able to calculate how much of their behavior is due to parenting within family environment And here's what we find The peak years of parental influence are below seven From seven on to 12, it drops dramatically After 15, it's 6% 6% of the variation in a teenager's behavior is how their parents raise them.

That's it and after age 21, it's zero There is no influence of parenting on any psychological trait after the age of 21.

Now, do not mistake what I am saying the knowledge your child possesses What they know is clearly a function of exposure in the environment but their traits, their abilities, their makeup, their personality is not So the idea that somehow we design these kids and we can get rid of ADHD needs to be abandoned The other research finding is the following, and it has been found in every single study There is no correlation between any trait of an adopted child and the people who raise them None If you think parenting is so powerful, prove it Otherwise, step back Accept your role as a shepherd.

Do it well and enjoy the show It's going to be a unique set of fireworks, I guarantee you that But now, not only do you not get the credit, you also don't have to take the blame you didn't cause this ADHD or whatever other disability your child has Your child, because of the executive deficit, is going to need to be made more accountable to others. We've already talked about a lot of this, but let's just go back over it in more specifics First, you need to be much more consistent with your rules and consequences in raising this child than normal parents need to be And that's not because you're going to engineer the ADHD out of the child.

It's because you're going to make this child less disabled from their ADHD by doing that. ADHD is not information deficit disorder, so kindly shut up Act. Don't. Yak The more you blather, the more you natter, the more you nag, the less influence you have So stop thinking that one more sentence will be enough to tip the scales in favor of obedience. It isn't. If I can just say it one more time, I know he'll listen.

So on the 20th time, there you are, fingers crossed behind your back So say it once, then back it up What these kids listen to more than anything are the immediate consequences, not the nattering, not the nagging, not the moral essays on why you should clean up your room to avoid meningitis. All right Now, with ADHD children, you've got to get their attention.

One of the easiest ways to do it, and also an affectionate way, is to touch them So I want you to put your hand on their arm, on their hand, or around their shoulder When you talk to them, I want you to look in their eye, and with that Clint Eastwood look, I want you to keep it short and sweet.

What do you want done? What are you trying to say? Or is this positive feedback? Is this approval? Is this recognition? Is this praise? Touch, then talk Keep it short, keep it sweet get to the point, and then back it up All right, if you're a parent with an ADHD child, you better be setting a timer to go off every few minutes and check on where that child is. This is to avoid accidental injury It is also to catch problems before they occur in order to be a proactive parent and I'll show you what we call the transition plan in a moment. I want you to increase the frequency of consequences for this child.

Your child needs much more external consequences and other people So there's no need to apologize for it. You're not going to turn them into some little materialistic kid, because he already is anyway Okay Okay, here's one. He's got a short attention span. Duh! Break the work into small pieces stop trying to torture his attention span to become longer than it possibly could ever be So remember the 30% rule, reduce the age by 30%, that's his attention span. I have to cut the work into that short a period So instead of 30 problems all at once, you get five Then you do them, bring them up to me.

I will take a pair of scissors and snip off the next five math problems and give them back to you This is how you're going to take exams. This is how you're going to do your work small chunks, frequent breaks not one chunk all at once By the way, that is better than giving extra time on an exam even to a college student extra time on an exam to someone with no sense of time is a dumb idea. You stole that from the learning disabilities because you didn't know what the heck else to ask for.

So I guess we'll just ask for extra time Well, extra time to somebody with this disorder is the definition of hell. You want to know why? Because if you have no sense of time, I want you to remember back to when you were five and it was the week before Christmas. What did that feel like, huh? Like molasses, this slow moving. Well that's what it feels like to somebody with ADHD and you just gave them an extra hour. Oh, great. They're up, they're out, they're out the door before you even know it.

I love this extra time recommendation because it's so stupid, right? What you should be doing is called time off the clock you get a stopwatch on that stopwatch is going to be the length of time everybody else gets Start the watch, and any time you like, you can stop it. Stand up, stretch, take a break, ask me a question, come back, start the watch. You will only get the same hour as everybody else, but you get to break it up as often as you like.

Will this take extra time? Of course, but that is merely a byproduct of the system of the strategy Whereas telling somebody they have extra time is not a strategy This is being done throughout the entire state of Indiana by the Educational Testing Service to prove that it is a more compelling accommodation for taking multiple choice time tests and is the old extra time which we already know is going to fail anyway break the work into pieces More frequent breaks, the work will get done You are going to have to use external timers. We've already talked about that.

Now, we want you to become proactive, not just in monitoring where your kids are but also in transitioning across activities so that when you are making a major change in what your family is doing with this child I want you to stop So everything stops. Okay, hold your horses, wait a second. It's homework time. So turn off the TV Stop the action, and then I want you to review two or three rules this child is to follow in the next activity.

Then I want you to set up what is the incentive, what's in it for him, what are you offering? Points? tokens, privileges, extra time on Nintendo or Game Boy or Wii or whatever, what are you offering? Next, what's the punishment? What's he going to lose? Make it clear You're going to lose that privilege, you're going to lose those points, you're going to lose that time on that computer, or you're going to time out. Make it obvious get the rules up front along with the consequences Now I want you to distribute the consequences throughout the task. You don't wait until it's over. There should be rewards every so often during the task, or they'll never finish.

Thank you then I want you to review with them. What do you think? How did you do? How could we do this better? Get their opinion. Invite them to self-evaluate the activity If you will do that, you will cut your problems by 50%. What do most parents and teachers do? They do reactive parenting. You go about minding your own business, doing your laundry, fixing dinner, until the problem occurs And now you are a problem-oriented person.

All you're doing is reactive firefighting, we call it had you just set your plan up front, whether it's before you go into a store or a restaurant or you start homework or we go to recess or we have friends visit or we go in grandma's house Every one of those is a major transition. You need to stop and do transition planning Now, what are you going to do when your child is not with you? You're going to get a behavior monitoring card like the kind we use for school, but this can be used anywhere, anytime.

It can be used for Cub Scouts, Little League, soccer, hockey going to a friend's house, spending the afternoon or evening or weekend with grandparents, having a babysitter Any place this kid is going to be and you're not there, you can monitor it with a monitoring card In the case of school, you're going to use these rules, and there's enough room for all of his teachers and classes to evaluate him using the rating at the top of the card one through five When this card comes home from school, every teacher will have rated this child at the end of every class, will have initialed it to insure against forgeries because they will forge this card.

So let's anticipate that All right, and then the parents are gonna review the card and the points are in parentheses. That's how many points you earn. And in the case of fours and fives, which are lousy ratings, that's how many points you lose You are then going to add up the points, subtract the negatives. That's what you got to spend in your home on your little token system, on your reward chart. But you could do this for anything. It could be for bus rides. It could be for lunchroom. It can be for recess. It can be for scouts.

I don't care If he is away from you and there's another adult there, that other adult can be evaluating your child frequently Whether it's every 15 minutes, whether it's at the end of every 45 minute class period as it is in school, doesn't matter. Frequent evaluation comes back to you.

You deliver the full consequences based on that card And here again, you can start to cut down problems by increasing accountability, even in places where you can't Alright, we've talked about the behavioral adjustments, we've talked about how to make these changes at the point of performance, but let's also face it, by themselves they're not enough Only a third of ADHD children respond enough to those changes to not need medication and even many of those would still benefit from their medication but two-thirds, and in my experience, it's as many as 80% are going to have to go on medication at some point in life Maybe it's not this month, maybe it'll be in six months, maybe it's a year Just depends on how compassionate and cooperative the caregivers happen to be.

And of course, how severe the ADHD happens to be as well But at some point, these medications will be needed for most children. So I want parents to know them and to know about them Now if you're looking for a very good book, the single best book for parents on psychiatric drugs is by Dr. Timothy Willens straight talk about psychiatric medication for children You can get it at the ADD warehouse. You can get it through Guilford Publications at Guilford. com Willens, W-I-L-E-N-S. It is a parent's book on psychopharmacology straight talk about psychiatric medication for children. So quickly, let's go over what's out there Right? First of all, parents need to know we have stimulants.

There are only two now We have had them since 1936 for the amphetamines and 1957 for methylphenidate. They've been around a long time, which means we know a lot about them We know how safe and effective they are. These are the best studied drugs used in pediatrics and psychiatry So parrots need to understand that. We got a lot of information out there on the safety and effectiveness of these agents but there still is only two stimulants. The news in the last seven or eight years has been in the delivery systems because the problem with the immediate release medications is they only lasted three or four hours.

So they had to be given two to three times a day.

So you had to take them at school and that created all kinds of problems So companies went back and re-engineered delivery systems to try to keep the drugs in the body for longer periods of time on a single dose And they came up with four ingenious delivery systems called the five Ps, which I will tell you about in just a moment Let's also understand that last year was published the biggest study ever done of stimulant safety for preschool children with ADHD and they show that the drugs are effective and are safe down to age two So the fact that we are seeing some of these drugs instituted younger in life than previously is nothing to worry about It looks okay The preschoolers don't respond quite as well But apart from that, there are no new side effects, and there's certainly nothing life-threatening about using them The other new agent we have out there is Atamoxetine.

This is Stratera, approved in 2003 in the US and about a year later here in Canada. Stratera is not a stimulant. It is not an abusable drug and it is nearly as effective, though not quite as effective, as the stimulants. But for some children, with particular ADHD comorbidities like tics, anxiety, Tourette's, OCD, insomnia and so forth, adamoxetine can be a good alternative drug because it doesn't worsen those comorbid conditions Now you should also be aware that this August, the US will have a new drug on the market for ADHD. It will be guanfacine XR Kwanfusin XR will be called Intuniv This is not a stimulant. This is an antihypertensive drug.

It has been used for years with ADHD children, especially if they have Tourette syndrome or bipolar disorder or very explosive behavior emotional impulsive behavior in the individual But Shire has now been able to manufacture a long-acting version of guanfacine, previously called Tenex and it will be marketed under the Guanfacine label I expect that you guys will probably see it a year or two after we get it Now let's go back to the five P's. These are the new delivery systems. The first P is the pellet system, excuse me, the pill system. My apologies The pills are the original forms of the drug. Ritalin and dexedrine are in their original pill form.

They last about three to five hours So what's new? They put him in a pump This is Concerta. Concerta is a miniature hydraulic pump so that when you swallow this, there is powdered Ritalin on the outside of this little capsule and it goes to work immediately.

And then on one end of this capsule, barely visible to you, is a laser drilled hole at the end of the capsule Inside the capsule is a methylphenidate sludge in two doses A light dose at the beginning, double the dose in the afternoon When you swallow this, water is going to come into this upper chamber at a continuous rate and it's going to push down on this and like a tube of toothpaste, it's going to squeeze liquid Ritalin out for about 10 to 12 hours That is really neat and then the pill is excreted in the child's excrement. So you've got a drug that can last around 10 hours.

Some kids it's only eight Others get as much as 12, but about 8 to 10 is about right That is a really neat system The next system is the time release pellet system So we've got the pill, the pump, and now the pellet. The time release pellets are what Adderall XR involves Focalin LA, or XR, Ritalin LA, they're all time release pellets And Guantanamo XR is going to be the same way So you have different pellets of medication, in this case amphetamine. They're coated with different time release coatings.

Some dissolve right away, some in an hour, two, three, four, up to eight to 10 hours So is there any difference between the pellet system and the pump? Not really over the day but on the time of day there is The pellet system is better if the problems are greatest in the morning.

The pump system is greater or better if the problems are toward the afternoon or late in the day But other than that, across the day, they cover about eight to 10 hours Excuse me, I want to get rid of that Okay, hold on The next P, I don't know if you have this up here in Canada This is the patch, okay, this is day Toronto This is methylphenidate in a skin patch.

Wear it on the buttocks, wear it on your shoulder, on your hip Wear it all day long That's it, it's absorbed through the skin, no taking pills This is a very hard drug to abuse because you can't snort the patch But there's a problem about 15% to 18% of patients develop a skin rash to this and can't tolerate it, and it's due to the drug Bye 80, 84% of the people can tolerate the skin patch So it's pretty good as an alternative Oh, by the way, I meant to mention under the pellet system, one of its advantages is if a child can't swallow a pill and you don't have the patch available you can open the capsule and sprinkle the pellets on food, like on yogurt or applesauce.

Doesn't change the delivery at all So that's another advantage of that.

Finally, last August, we have the first drug of its kind ever produced This is Vyvanse, it's a form of amphetamine It's called a prodrug, hence the last P What is a prodrug? A prodrug is where you take a chemical, in this case amphetamine and you lock it up Okay, this is the amphetamine right here, and you lock it up with another chemical So it can't work Now this drug will only work after you split off, in this case, the lysine You swallow vive-ance There's a chemical in your body that will split off the lysine And now the amphetamine can go to work This is the first non-abusable amphetamine ever invented because it only works in the stomach and the heart and after it crosses through the intestine into the bloodstream And that's where the The chemical is the enzyme that splits off the lysine And now it goes to work It's probably coming this year, I believe Okay So just be aware that it's down there Vyvanse is a little better than Adderall XR, which is the other drug made by the same company, and it's replacing it in the US because Vivant lasts two hours longer than the other drugs do This is about a 12-hour drug It also has a softer onset and a softer offset, unlike Adderall So it's a pretty good drug I want parents to understand there are misconceptions afoot about the stimulants They are not addictive as prescribed unless you inject or inhale them.

They do not produce aggression and they didn't cause Columbine They are in fact able to reduce aggressive and antisocial behavior. They do not cause seizures. You'd have to swallow the whole bottle So even children with seizure disorders can take these drugs safely. They do not cause tics or Tourette's unless you already are prone to ticks or to rats, and then they may bring them out and make them worse even then only in about 30% of the cases The remaining cases do not experience a worsening of of their tics and so children with ADHD and tics can take these drugs safely as long as they're not one of the 30% that makes it worse.

And by the way, the worsening is temporary Stop the drug, the ticks will go back to their baseline within a week Are we overdosing ADHD children in North America? Absolutely not If you look at the prevalence of the disorder, it's 7. 5% If you look at how many children are taking medication, it's between 4 and 5% which means you are missing a third of all children And by the way, 90% of all adults with ADHD are are not treated So, are we using more medication than ever before? Yes. Is it scandalous? No What's our problem? We still have people who don't have access to care and who aren't being treated for their disorder.

And that's the real problem, as our Surgeon General pointed out not over-treatment in the United States or up here Is there a risk of later substance abuse from the stimulants? Your own CBC ran a program on Marketplace Is that what it's called? Right? The one with that little blonde hottie that used to date your member of parliament? I just want to make sure I got the right program, that's all. Everybody knows when I say that. Oh, her! Yeah, we know. Okay I have a bone to pick with that because they were in fact deceitful in their creation of that program, especially with our medical school.

But nevertheless, they ran a program claiming that stimulants can predispose children to cocaine abuse, nicotine, and other drugs of abuse later in life if your children took them. This was based upon a single study done by Nadine Lambert in San Francisco Nadine's study has many, many flaws in it, not the least of which is she never controlled for conduct disorder, which is the biggest predictor of drug abuse among ADHD children. And when you control for that, there is no link between being treated with a stimulant and abusing any drug.

How do I know that? Because 17, you can correct this slide, 17 studies, including my own have now shown no relationship between length of time you take a stimulant throughout childhood and risk of any abuse in adulthood So there's your box score, 17 to 1. What did the CBC focus on? The 1 Why? Because we all know now that Televised journalism is a form of entertainment not a form of information that they go after the scandal the underbelly, the sensational side, and they ignore anything that does not fit that preconceived idea. And that's exactly what the CBC did which was, I think, a travesty of journalism Do they improve academic achievement? No, not at the start.

But we now have several studies, including one published a week ago that show that if you stay on your medication at least two years or more, we do start to see an uptick in academic achievement skills But prior to that time, what the drugs are doing is improving your productivity the amount of work you do but there's no knowledge in a pill So why would you know your multiplication tables when you take your concerto when you didn't know them the day before, right? but what the drugs do is to make you available for learning And if you stay available for learning over a long enough period of time, you do learn more but not in the short run And then I mentioned Stratera.

I'm not going to go over that because I've already mentioned it. But it is the non-stimulant on the market right now. And as I said, we will have another one later on. It's a very good drug especially for kids who have anxiety or tics or OCD or insomnia or other sleep problems. Okay, the next thing I want parents to understand is to avoid treatments that we know don't work or that have a very low probability of succeeding By the way, if these don't correspond to your manual exactly I changed a few of them yesterday. I try to keep my slides as up to date as possible.

Or when I go through them and I don't like the teaching, the flow, I may change them a little bit. So if you're not seeing exactly what I have, my apologies you've got 99% of what I've been talking about These are the things to avoid. Why? Because either they're so silly, we're never gonna look at them or they've already been looked at and they don't work Taking something out of the diet benefits about one out of every 20 ADHD children.

We're talking here about colorings flavorings, and preservatives Do some ADHD children react adversely to these? Yes Do most know It's mainly children five and younger and it's about 1 in 20 So, do we recommend elimination diets as a blanket panacea treatment for ADHD as was done by Feingold and others? No Might it benefit the occasional rare child? Yes Next, there is nothing you can put in the diet that treats this disorder So whether it's antioxidants, whether it's the fish oils, whether it's megavitamins We have yet to find anything that benefits ADHD The fish oil study, the best one, was published just a month ago by the Swedish research team in Gothenburg best trial I've ever seen and they reported very sobering negative results.

Only 25% of the kids responded. It was mainly the inattentive SCT kids. The degree of response was very slight So even they recommended against it. Any positive reports you've heard? or not from well-controlled studies Now I'll get to my questions in just a moment. Yeah. Sure Thanks Thank you Thanks, Heidi, I'm sorry about that Yeah Okay Next, fastest growing treatment in the US school system right now for ADHD is sensory integration training.

This is a special set of exercises done by some occupational therapists who have gotten additional training in the SI techniques and in assessing for sensory integration problems, this has been resoundingly disproved So this is an area that has been studied, but you'd never know it by the number of people being exposed to this treatment It has proven to be of no benefit for LDs or ADHD even their own journal published a meta-analysis that showed that. And yet we go on seeing sensory integration being offered as a special set of exercises to treat ADHD.

Why would massaging the head do anything for ADHD, yet chiropractors do? engage in what is called skull massage or neurologic organization training claiming that they can successfully treat ADHD through skull massage. It's a silly idea. We won't go there Play therapy has been tested.

It does not work for ADHD because ADHD does not arise from environmental stress So why would helping children cope with stress solve this problem? That does not mean it may not benefit anxious children, PTSD children, or children with depression but it doesn't benefit ADHD children for their ADHD Self-control training, I mentioned earlier, this is talking to yourself So teaching children to talk out loud as they perform a task, we had great hopes for this, and it failed But the diamond in that dung heap is that we found that it was age-related The younger you are, the less likely it works But by late adolescence to adulthood, it does work but only if you're on medication It is a supplement to medication, not a form or alternative to medication.

There are several books on the market now that were developed by these researchers. One is Steve Safran at Harvard Med School He now has a cognitive therapy manual for adult ADHD and the other is by Russell Ramsey at University of Pennsylvania You can find both of these at Amazon or at theADDwarehouse. com if you're into adult ADHD treatment.

Social skills training should not be done for the average ADHD child unless it's being done at school or with the peer group with whom he is having trouble and then it should be mostly practice, cuing, and rewarding the use of the skill and a lot less time spent in training the skill What's the proportion? 80-20 80% altering the point of performance, 20% training in the skill And if you follow that balance and you do it out there where it matters, it might have a chance If you do it in a clinic with the kids, he'll never see again the rest of his life.

It doesn't work Next to the last idea for you, right? 25 to 35% of the parents of ADHD children are ADHD themselves It used to be people didn't care. They didn't ask. They didn't want to know, or they didn't think it mattered Now we know it matters First of all, it matters that your own ADHD needs to get treated because we've studied now the impact of ADHD on parents whether they have ADHD children or not We now have a series of studies, particularly the work of Charlotte Johnston at University of British Columbia and Andrea Kronis at University of Maryland who have now studied parents who have this disorder and what it does to their parenting.

And you can see the obvious things here greater impulsiveness, higher rates of expressed emotion, greater greater rates of disciplining lower rates of parental monitoring of children all of which increases the risk for oppositional disorder in the child So, the parent's ADHD needs to be detected and managed, not just the child's ADHD. And also, more recently, it is the best predictor of who fails in behavioral parent training the parent themselves has the same disorder.

My last admonition to you is one that Leo Bascalio wrote about 30 years ago in his book for families of retarded and autistic children In this book, Pescalia said one of the most important things a family of a disabled youngster can do is to be a good parent is to practice forgiveness And he meant by this four things You better get good at forgiving yourself for your mistakes. You will make them. We all make them. Even raising normal children, you will make more of them Because ADHD children know just how to push your buttons to get you to do things you regret So you better get good at forgiving yourself those mistakes.

And if Judy Harris is correct, you don't matter anyway You're not as important as you thought you were So relax a little bit. It's OK. You know what really matters, as Miskalya said? you try to get it right the next time It's not, did you make the mistake? It's what are you going to do about it tomorrow to make sure that it doesn't happen again. That's a very important idea.

One of the things that I think will be very helpful in helping you to do this is to step back to that principle about being a shepherd You're not an engineer So it matters what you do, but it doesn't matter that much what you do And I find it's better if you have the shepherd's view because you start to look at your children in a very different light as things to be enjoyed and celebrated and cherished for their uniqueness as opposed to being mounds of clay that you can sculpt into whatever you choose to do You just don't have that kind of power The second area of forgiveness is that of your child.

This is harder Okay, this is harder because resentment can build up, the mistakes are there, the misbehavior is there. You are being given misbehavior 24-7 that you have to deal with.

You have had to step up to the plate and become your child's frontal lobes And it's not easy, it is exhausting And there's a tendency among some parents to allow a certain amount of resentfulness to creep into this I wish that you had a different child, a better child, a normal child And boy, that is just one step away from justifying child abuse The idea that your child may be doing this intentionally is one of the sources of resentfulness So you better get good at forgiving these kids their mistakes. They make a lot of them.

So here's a couple of suggestions that parents have told me about that work for them, and I love these ideas and I put them in my parents' book Number one at the end of the day after dinner when you're having your coffee or your cognac or whatever want you to take out a sheet of paper I want you to write down all the problems you had with this kid today. Write them all down. Every one of them. All right? Exercise your demons Get them down on the paper I don't want you to go to the sink, take a match and light them. I want you to burn them all up. There they go. Shhh.

Gone You have now performed the ritual exorcism. The demons are gone, the day is over, let it go. All right The second thing one of the parents taught me that she found was so useful is after your child has fallen asleep Go upstairs sit on the floor in a yoga position, you know and watch your child sleep Just Breathe in and out and watch, there is nothing more innocent and watching a young child sleep And if that doesn't renew your batteries and restore your balance to your view of your child, I'm not sure what will Maybe a glass of wine while you're watching the child.

Thank you But whatever it takes to let these go and to try to get better tomorrow, that's what really matters not the mistakes you make. And the same applies to your partner or your spouse Don't get all upset because they're not doing it quite the way you want it done or vice versa And then of course, the last one is the one you're all here for, I hope, as well and that is to learn more about ADHD.

But in learning, you realize that the public doesn't understand this disorder the way we do that they are ignorant of this disorder and its causes So you better get good at forgiving other people who glare at you in Walmart because your child is a handful, who stare at you in the Outback restaurant who look at you as if this is your fault. My sister-in-law has an ADHD son. This is my nephew, Dan One time she was in Target And an older woman came over to her and said, Why don't you control your child? You know, this is all your fault.

If young parents like you would just take this bull by the horns and discipline these kids more, we wouldn't be having these problems. And she followed my sister-in-law out to the car, at the car, stood there yelling at her while she locked her door, and she was in tears over this. Now that's an extreme example, but don't tell me this can't happen Most of you have had these looks thrown at you about your child, and sometimes it goes up a notch So you better get a thick skin about the public that doesn't understand this disorder Now there's a cognitive therapy technique that you can use.

While you're looking at these people, you can be saying in your mind, what are the things that I'm doing? What's it to you, pork face? But I don't want you to say it out loud. This is just cognitive therapy. You're an idiot. You don't know what you're talking about. If you had one of these kids, walk a mile in my shoes, but just show me Shut up, drive on, get on with your life. But you better get good at forgiving the public their misunderstanding, because boy, do they misunderstand this disorder I'll hang around for a few questions, but I hope you enjoyed the 30 things families need to understand about reason.

Thank you on medication? No, because in 55 to 65 percent of the cases of children, the medication will normalize them So that's over a half, and in some cases, two thirds The 30% is gone only when the medication is active So at the end of the day, here it comes, and by 8 o'clock at night, you're back to 30% again So just keep in mind that it can normalize some children. In the remaining 30%, the gap is closed, but not completely There is improvement, but not normalization.

Other things will have to be done to help with that gap And then there's about 10 to 15% of the kids who don't respond to any particular agent And in that case, you're just going to have to deal with the full 30% and accommodate it as best you can So good question that there's one best way because let's face it, And it's best that your child find another set of friends are fairly reasonable people and I think if you went to them, if you downloaded a fact sheet on ADHD from my website or the CHAD website And you just took it to them, this sort of two to three page description Or you call them and say, you know, I've been meaning to come by or have you over for a coffee or as part of this little social coffee clutch or whatever, you introduce this information about your child, about their diagnosis, about what it is and the various things that you all are trying to do to contend with it.

I think you might find these people being more compassionate than they are ordinarily would. They're probably laboring under a lot of misimpressions that the public has anyway, that this, your child could be better, this is your fault, it's a result of parenting, and we sort of need to disabuse them of those ideas. But I like the honesty is the best policy approach to begin with.

Now obviously if in the middle of this conversation It becomes very clear that these parents don't care, don't understand, and don't want to then you should not be allowing your child to play at their home or under their supervision Feel free to invite their child over to your house if they'll allow it, but I still think informing the public We've had some teenagers carry around a card about ADHD in their wallet so that they can show it to people who are not familiar with ADHD, a coach or a policeman that pulls them over for speeding or something like that.

But Very much like we got the idea from the Tourette Syndrome Foundation, which publishes small cards that are information that allow Tourette's people to share the information without necessarily having to explain it all themselves, but here's a sheet from a reputable source like Chad or my website that they can learn from. The most you can do is to try to persuade them, inform them, maybe change their mind. And then the rest is shopping for more reasonable friends and parents of friends if you can. Now some people ask, well, my child doesn't have an awful lot of friends. What can I do to help? to try to improve that.

Make your house the best place to play on the street. It's bribery, but I don't care how you do it.

You need to have the best toys in the yard, you need to have the best games in the house, you need to be somebody who feeds all visitors So that when everybody, when anybody shows up, man, there's a fudgesicle in your hand and an Oreo and a glass of milk and here's the Wii system and I mean, you are just going to create this place where they love being there whether your son is there or not, right? And hopefully some of these friendships will stay or take, or they'll be a little more forgiving of your child's immaturities because you're such a great place to be However you can arrange this environment, you can't make other children like your child That is not possible to do You can only make them more like a bull, or make the environment in which your child exists more like a bull And hopefully, some of that sticks So approach it that way, but you can't make another child want to play with your child.

It's just not going to happen. Those children make their own choices There are a number of treatments on the market right now that are based on these neuropsychological theories of ADHD as an executive disorder particularly that involves working memory Torgal Klingberg is the developer of Cogmed. He's a Swedish scientist Cogmed is is a is working memory training. It's practicing digit span forward and backward and spatial memory forward and backward for about 45 minutes a day with your child. You do need to reward them because this gets boring to tears after the first day or two So you have to have a token system and a reward program in place.

Program costs several thousand dollars Now, I have visited Sweden and his lab. I've gone over their data And it does look like this produces a temporary improvement in working memory, and that results in a temporary decrease in ADHD symptoms But even Klingberg has shown that with three months of training or up to six months of training, the effect might last maybe three months and then you have to start the retraining again. So he likens it, I think very aptly, to an athlete like a weightlifter trying to train muscle mass This isn't anything willful. You're just trying to expand the capacity of the brain for working memory.

And just like an athlete who exercises, I can build up my biceps But if I stop exercising for a month, guess what's going to happen? my bicep is going to atrophy now because it's not being exercised as much. And the same is true with these neuropsychological training programs that we have seen so far Now Klingberg gets royalties from the company, and we would like to see his research replicated by someone who does not have a financial stake in the success of the company. So it is being tested at five universities in the U. S.

I know of at least one here in Canada as well When these studies are over, we're going to have an idea about whether his findings could be replicated But even if they are replicated, let's not forget what he found, this is a temporary error. And I think that's a good thing exercising program that has to be reinstituted several times a year to sustain the gains. Now, let me tell you something else.

If it turns out that this works Why would you spend several thousand dollars when you can buy a Nintendo DSS and the Brain Age software, which does both of these things as well as at least six other frontal lobe executive function tasks? It's just as much fun if not more so it's one-tenth the cost So I would direct you to Nintendo before I would say, send you to Cogmed. And if you don't want to invest the couple hundred bucks that DSS costs with the software, you can go to Cogmed Get Scientific American Mind This is the popular science magazine Scientific American.

They also publish one called Scientific American Mind The last issue of mind was a review of all internet sites that have executive function training programs on them where you can go, some of them are free, most of them have a monthly fee that you can sign on for, and there's the software, there's the games, there's tracking your successes and failures. All the things that Nintendo and Cogmed are doing can be done through these websites without buying the equipment, usually for like nine or ten bucks a month Some are more, some are less. Some are more interesting, some are less interesting.

But there is a review of all of these brain training websites in that magazine, and it's very good By the way, Nintendo comes out looking really good because it's the only portable system you can take anywhere and practice anytime, even if you're waiting in a car for Little League to start You know, so look around. Cogmed isn't the only thing out there. But let's wait for the research to come out before we know whether this is really gonna turn out to be a coping tool and that's all it is. It is not a cure, not by any means. That was probably more information than you ever wanted to hear Alright, here is the relationship.

The relationship between ADHD and bipolar is a one-way street. ADHD children carry no elevated risk for bipolar disorder over that of the general population No longitudinal studies have found that to be the case, my own included, not the Canadian studies, not the New York studies, not the Iowa, not the Swedish, not the Australian. Risk is 2-4%, which is the population rate So if a child starts out ADHD, that's probably what they're going to stay.

Bipolar becomes a very remote diagnosis However If there is bipolar disorder in the family, the risk goes up eight times Now The real relationship is from bipolar to ADHD If a child has bipolar disorder already, And it started in childhood The risk is 80 to 97% that they will have ADHD along with it.

And that is why the confusion People saw that so many bipolar children had ADHD, they made the leap that the opposite had to be true that ADHD was a big risk for bipolar and it turned out to be no risk for bipolar disorder unless the family history of bipolar illness is there And then the genetic risk for bipolar disorder, obviously, are what mediate that high risk So bipolar disorder, only if it starts in childhood, carries a very high risk for ADHD along with it. And ADHD is usually the first disorder to start If the bipolar starts in adolescence, the risk is 40 to 45% that ADHD is with it.

If it starts in adulthood, which is the more typical form of bipolar disorder, the risk is only 20 to 25% So notice it's the early onset bipolar that brings the risk of ADHD with it, not the other way around. Now, if there's bipolar there, and it started in childhood, it is one of the worst psychiatric disorders a child can have, barring infantile autism or schizophrenia very difficult to manage, it requires multiple medications to try to deal with it There is obviously an increased risk of not just destructiveness, but violent behavior, particularly in males.

There is periodic hospitalization for safety as well as for re- engineering, the psychopharmacology that is testing the drugs, many of the drugs used with bipolar disorder have far more serious side effects than the ADHD drugs do And so children are often hospitalized partly to monitor the side effects as they're titrating them A bipolar child has a massive increase in risk for suicide and drug abuse as they enter adolescence So this is not a fun disorder But it's 2 to 3% roughly of children have the bipolar disorder. And it is severe, and it is usually lifelong, and it often requires polypharmacy and periodic hospitalization. So the news isn't good.

But at least we can say ADHD is not a cause of bipolar disorder. Most ADHD children are never at risk for it but if there's a family genetic link to bipolar then that young child with ADHD may also carry that link and that risk studies of the stimulants. There are additional studies of the other drugs like adamoxetine. The placebo rate in most studies is between 10 and 35 percent The rate of responders to the active medication is between 55 and 92 percent, averaging to about 75 percent. So it's twice the placebo rate.

So at this point, we can be assured from these randomized placebo-controlled studies that the medication has a real effect, not just an effect of psychological significance adjustability as the placebo effect might suggest So all I can tell you is those studies have been done, they've been done repeatedly, and we can be assured this is not a placebo effect. It doesn't mean there isn't a little bit of a placebo effect, but most of the effect is clearly that of an active agent .



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