This is how you treat ADHD based off science, Dr Russell Barkley part of 2012 Burnett Lecture

Summary

The transcript delves into the intricacies of ADHD, emphasizing that it is not merely an attention disorder, but an executive functioning disorder. It affects multiple levels of cognitive function, impacting behavior and time management. The speaker advocates for a comprehensive approach to treatment, combining medication with environmental modifications to support individuals with ADHD. Key strategies include making mental information physical through reminders, breaking down tasks into manageable steps, and creating immediate consequences to enhance motivation. The importance of physical exercise and maintaining blood glucose levels for cognitive function is also highlighted. The summary underscores the treatability of ADHD with the right combination of neurogenetic therapies and psychosocial interventions, stressing the need for increased recognition and treatment to prevent the disorder's secondary harms.

Takeaways

• 🧠 ADHD is primarily a performance disorder, not a knowledge disorder. People with ADHD know what to do but struggle to execute it.
• 🕰️ ADHD causes 'time blindness', making it difficult for individuals to plan and aim their behavior towards the future.
• 🚫 The issue with ADHD is not knowing what to do, but rather the inability to do it, which is a disorder of 'when' and 'where', not 'what' and 'how'.
• 💊 Medication plays a crucial role in treating ADHD due to its neurogenetic basis, with 80% of those with ADHD likely to be on medication at some point.
• 🤸‍♂️ Executive function training alone is not sufficient. The environment needs to be engineered to support individuals in demonstrating their knowledge.
• 🔄 Accountability needs to be tightened for those with ADHD, bringing consequences closer in time to address the issue of delayed consequences.
• 📝 Making mental information physical through cues, signs, charts, and reminders can help externalize information and support those with ADHD.
• ⏳ Time needs to be made physical through the use of clocks, timers, and other visual aids to help individuals with ADHD gauge the passing of time and their performance.
• 📉 Breaking down lengthy assignments into smaller, manageable steps can make tasks more achievable and reduce the impact of delays.
• 🏋️‍♀️ Physical exercise and maintaining high blood sugar levels through proper nutrition can boost the executive function 'fuel tank'.
• 🧩 Using tangible, hands-on tools to assist with problem-solving can be beneficial for those with ADHD who struggle with mental manipulation.
• 📈 The success of interventions for ADHD depends on the willingness of others in the individual's environment to support and implement necessary changes.

Q & A

What is the main issue with ADHD according to the transcript?

The main issue with ADHD is not a lack of knowledge but a performance disorder where individuals know what to do but struggle to execute those actions. This is due to impairments in executive functions, leading to what is described as a 'disorder of the when and the where,' not the 'what and the how.'

Why is medication considered a justifiable treatment for ADHD?

Medication is considered justifiable for ADHD because it is a neurogenetic disorder. The use of neurogenetic therapies, such as medication, plays a role in managing the disorder, with 80% of people with ADHD expected to be on medication at some point in their lives.

What is the concept of 'scaffolding' in the context of treating ADHD?

Scaffolding refers to the support structures or systems put in place in the environment of a person with ADHD to help them perform tasks they know how to do but struggle to initiate or complete. This involves creating external reminders, cues, and structures that guide their behavior.

How can the accountability for individuals with ADHD be improved?

Accountability can be improved by creating a system of immediate and frequent consequences for actions. This involves 'tightening up accountability' and making the consequences of their actions more immediate and tangible, which can help motivate individuals with ADHD to perform tasks.

What is the significance of making mental information physical for someone with ADHD?

Making mental information physical is crucial because individuals with ADHD often have a shorter working memory. Using visual cues, signs, charts, and reminders can help externalize the information, making it easier for them to remember and act on what needs to be done.

How can long-term assignments be managed effectively by someone with ADHD?

Long-term assignments should be broken down into smaller, manageable steps or 'baby steps'. This approach reduces the delay often associated with large projects and makes the task more approachable, allowing individuals with ADHD to work through it incrementally.

What role does physical exercise play in managing ADHD?

Physical exercise, particularly aerobic exercise, is beneficial for individuals with ADHD as it helps to boost and refuel the executive function 'tank'. Regular physical activity is associated with better executive functioning and is recommended as part of a comprehensive treatment plan.

Why is it important to keep blood glucose levels up for individuals with ADHD?

Blood glucose in the frontal lobe is directly correlated with executive abilities. Maintaining higher blood glucose levels, especially during tasks that require significant executive function, can help keep the 'fuel tank' of executive functioning partially restored and prevent cognitive fatigue.

How do video games differ from homework in terms of motivation for individuals with ADHD?

Video games provide external, continuous reinforcement, which creates motivation without the need for internal motivation. In contrast, homework often lacks this immediate reinforcement, making it harder for individuals with ADHD to stay motivated and focused.

What is the '10 and 3 rule' mentioned in the transcript?

The '10 and 3 rule' is a strategy for managing ADHD by having individuals work for 10 minutes and then take a 3-minute break. This approach allows for regular refueling of the executive function 'tank' and prevents cognitive overload.

Why is it crucial for the people around an individual with ADHD to be involved in their treatment?

The success of interventions for ADHD relies on the willingness of people in the individual's natural environment to make changes, such as building 'ramps' or 'scaffolding'. This involvement is necessary to create a supportive environment that can help the individual with ADHD manage their condition effectively.

What are some of the programs mentioned for adults and college students with ADHD?

The transcript mentions Steve's or Russ Ramsey's program, which uses cognitive behavioral therapy, Steve Saffron's program, and Mary Santo's program for training executive functioning in adults with ADHD. These programs are designed to boost medication effects and target executive deficits.

Outlines

00:00

🧠 Understanding ADHD as a Performance Disorder

The first paragraph explains that ADHD is not merely an attention issue but a performance disorder affecting the brain's executive functions. It emphasizes the distinction between knowing what to do and actually doing it, which is often the challenge for individuals with ADHD. The speaker discusses the importance of interventions that address the environment to support individuals with ADHD, highlighting the role of medication due to the neurogenetic basis of the disorder. The paragraph also touches on the potential for training executive functions and the necessity of immediate consequences to improve accountability and behavior.

05:01

🛠️ Strategies for Managing ADHD and Executive Deficits

The second paragraph delves into specific strategies for managing ADHD. It suggests making mental information physical through external cues and breaking down lengthy assignments into smaller, manageable steps. The paragraph also addresses the need to create external motivation, as individuals with ADHD often struggle with internal motivation. It discusses the importance of manual problem-solving aids for those who have difficulty with mental manipulations and the concept of the executive system's limited 'fuel tank,' which needs to be refilled through rewards, positive emotions, breaks, and physical exercise. The role of blood glucose in maintaining cognitive function is also highlighted, with advice on maintaining blood sugar levels during tasks that require significant executive function.

10:03

💊 Treatment Approaches for ADHD

The third paragraph focuses on treatment approaches for ADHD, stressing that it is the most treatable disorder in psychiatry with a range of effective medications and psychosocial interventions. It mentions specific programs designed to boost medication effects and target executive deficits in adults with ADHD. The speaker highlights the high response rates to ADHD medications and the importance of recognizing and treating the disorder. The paragraph concludes with a call to action for healthcare providers to ensure that individuals with ADHD receive appropriate treatment, emphasizing that the biggest issue is not over-treatment but under-treatment of the disorder.

Keywords

💡ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, impulsivity, and hyperactivity. In the video, it is discussed as an executive disorder rather than an attention disorder, emphasizing its impact on executive functions such as planning, organizing, and time management. The speaker highlights that ADHD affects various aspects of daily life and requires a multifaceted approach to treatment.

💡Executive Functions

Executive functions are cognitive processes that enable an individual to plan, initiate, monitor, and adjust behaviors to achieve a specific goal. The video emphasizes that ADHD disrupts these functions, leading to difficulties in areas such as time management, impulse control, and emotional regulation. The speaker discusses strategies to support individuals with ADHD by re-engineering their environment to compensate for these deficits.

💡Performance Disorder

A performance disorder, as mentioned in the video, refers to a condition where an individual has the knowledge but is unable to effectively apply it in practice. This is a key issue in ADHD, where individuals may know what they need to do but struggle with the execution. The video discusses the importance of creating 'scaffolding' or support structures to help individuals with ADHD perform tasks they are capable of understanding.

💡Neurogenetic Deficits

Neurogenetic deficits refer to genetic influences on the brain's structure or function. The video explains that ADHD is associated with such deficits, which justify the use of medication as a form of neurogenetic therapy. It is suggested that these deficits affect the brain's executive functions, contributing to the symptoms of ADHD.

💡Scaffolding

In the context of the video, 'scaffolding' refers to the support structures or environmental modifications that can assist individuals with ADHD to perform tasks and manage their executive functions more effectively. The speaker uses the term to describe the need for interventions that help bridge the gap between knowing what to do and actually doing it.

💡Accountability

Accountability in the video is discussed as a crucial factor in managing ADHD. The speaker suggests that individuals with ADHD need to be held more accountable for their actions due to their difficulties with delayed consequences. This can be achieved through structured programs that provide immediate and clear consequences for actions.

💡Externalizing Information

The concept of externalizing information involves making abstract or mental information tangible or visible. The video suggests that individuals with ADHD benefit from having information presented in a physical form, such as using signs, charts, or reminders, to help them remember tasks and manage their time more effectively.

💡Blood Glucose

Blood glucose, particularly in the context of the frontal lobe, is highlighted as a key factor in supporting executive functions. The video explains that maintaining blood glucose levels through fluids like lemonade or sports drinks can help boost the 'fuel tank' for the executive system, which is beneficial for individuals with ADHD during tasks requiring cognitive effort.

💡Medication

Medication is presented in the video as a vital component of ADHD treatment, serving as a neurogenetic therapy to address the disorder's genetic basis. It is noted that a significant portion of individuals with ADHD will be on medication at some point in their lives, and it is considered the most effective treatment available.

💡Psychosocial Treatments

Psychosocial treatments encompass a range of therapeutic interventions that address the social and psychological aspects of a condition. In the video, these treatments are discussed alongside medication as essential for the comprehensive management of ADHD. The speaker mentions specific programs designed to boost executive functioning and improve outcomes for adults with ADHD.

💡Time Blindness

Time blindness in the video refers to the difficulty individuals with ADHD have in perceiving and managing time effectively. This can result in challenges with planning and organizing tasks over time. The speaker suggests strategies such as using timers and breaking down tasks into smaller, manageable steps to help individuals with ADHD overcome this issue.

Highlights

ADHD is not an attention disorder but an executive disorder, affecting multiple levels of cognitive function.

ADHD impacts five levels of executive functioning and seven executive functions, leading to 'time blindness' and difficulties in future planning.

Individuals with ADHD have an intention deficit disorder, knowing what to do but struggling to execute it.

The primary issue in ADHD is not knowing what to do but rather the inability to perform known tasks.

Interventions for ADHD should focus on the environment where the individual is not performing, using 'scaffolding' to support their performance.

Teaching skills alone is insufficient for treating ADHD; the environment must be re-engineered to help individuals perform.

Medication is a justifiable and effective treatment for ADHD due to its neurogenetic basis, with 80% of individuals with ADHD using medication at some point.

There is a possibility that practicing certain executive functions like working memory might help, although evidence is not yet conclusive.

Accountability is key in addressing executive deficits, requiring more frequent and immediate consequences to improve behavior.

Behavioral interventions like the Token Economy (BOD) can introduce artificial consequences to improve functioning in individuals with ADHD.

ADHD is a chronic disorder, often compared to diabetes, requiring daily management to prevent secondary harms.

Approximately one in six people may outgrow ADHD, but the majority continue to experience symptoms into adulthood.

To help those with executive deficits, six steps are outlined, including making mental information physical and managing time effectively.

Long-term projects should be broken down into smaller, manageable steps to avoid delays and enhance the ability to complete tasks.

External motivation is crucial for those with ADHD, as they often cannot generate it internally, necessitating environmental support.

Problem-solving should be made manual for individuals with ADHD to assist with tasks that require mental manipulation.

The executive system's 'fuel tank' is limited, and activities like rewards, positive self-statements, and breaks can help to refuel it.

Physical exercise and maintaining blood glucose levels are essential for boosting the executive system's capacity in ADHD.

ADHD is the most treatable disorder in psychiatry with a range of effective medications and psychosocial treatments available.

Underdiagnosis and undertreatment of ADHD are significant issues, with only a minority of affected individuals receiving appropriate care.

Transcripts

so I want you to understand that you

have a brain the back part of it is

where you learn the front part is where

you do knowledge performance knowing

doing and ADHD splits them apart I don't

care what you know you won't use it you

can be the brightest kid in the world

not going to matter so you got a real

problem on your hands because you can

know stuff and you won't do

stuff that's a serious problem called a

performance Disorder so what we know

about ADHD is it's going to put all five

of those levels at risk because it

interferes with all seven executive

functions and you're going to have time

blindness and you won't be able to aim

your behavior toward the future to care

for yourself as effectively as other

people are able to do you have intention

deficit disorder you have a disorder of

performance not knowledge you know what

to do but can't do it you have a

disorder of the when and the where not

the what and the how your problem is not

with knowing what to do it's with doing

what you

know what does that mean it means that

all interv ventions must be out at that

place in the

environment where you're not doing what

you know to help you show what you know

I have to create scaffolding around you

to help you do this what does this mean

for treatment teaching skills is

inadequate it won't work you can sit

down with somebody with ADHD and tell

them what they need to do good luck

right it's not even going to leave your

office you act like they're stupid

they're not they know what to do they

know what you're telling them to do

right they're not going to do it when

they get out there that information has

no controlling value over their life and

it ticks you off you start to interpret

it as a motivational problem but the

only way to deal with executive deficits

is to re-engineer the environment around

them to help them show what they know

and all treatments must be out there in

their life where you have to build that

scaffolding all of this in ADHD is due

to neurogenetic deficits and that means

that medication is absolutely

justifiable after all if you have a

neurogenetic disorder then neurogenetic

therapies have a role to play in your

disorder and they do 80% of people with

ADHD will be on medication at some point

in their life and good thing it's the

most effective thing we have there are

other things we can do but that's the

most effective now you might be able to

train up some of these executive

functions we don't know that yet we

don't know whether practicing working

memory actually helped you in life

there's no evidence that it does at this

point at least convincingly but there's

a possibility what we do know is we are

not to excuse you from your mistakes

because the problem you're having is not

with consequences so why would I excuse

them the problem you're having is with

the delay to the consequence all

important social consequences are

delayed consequences and that's your

problem time so the solution to

anybody's problem with an executive

deficit is to tighten up accountability

to make you more accountable more often

to other people with more consequences

artificial as they may need to be but I

need to bring consequences very close to

you in time so I'm not going to excuse

your behavior I'm actually going to hold

you more accountable than other people

and that is why we do bod bod allows me

to sprinkle artificial consequences all

throughout the environment to improve

your functioning and that means that the

success of my intervention is based on

the willingness of other people in the

natural environment to make those

changes if they're not willing to build

ramps so to speak to build the

scaffolding it's not going to work the

stakeholders have to be involved it

means that ADHD is the diabetes of

Psychiatry it's a chronic disorder that

must be managed every day to prevent the

secondary harms it's going to cause but

there is no cure for this disorder now

about one in six people might outgrow it

maybe as many as one and three not sure

yet but the vast majority two-thirds are

going to continue to be ADHD in

adulthood and they need to view ADHD as

diabetes of the brain it's a chronic

Disorder so here are the things that my

theory tells you to do to help people

with executive deficits this is what I

told you this morning this is the

take-home cash value of Shifting your

framework from an attention disorder to

an executive disorder and the theory

tells you all six things you got to do

step one you have to make mental

information physical you must

externalize the information because

working memory is shot that means we

have to use cues signs charts reminders

doist I got to put stuff in your visual

field to remind you of what needs to be

done right here right now make it

external again the next thing I have to

do is make time physical real through

clocks timers counters watch minders

anything I can enlist that is going to

put time outside of you so that you can

see it passing and judge your

performance relative to it because you

have no clock we got to put one in in

your visual field I'm going to have to

take lengthy assignments because they

involve spans of time and get rid of

time make them small quotas little baby

steps over the bridge in time a little

bit of work done frequently over time

and will get you there but you will not

do book reports and science projects and

other things on your own you can't those

involve delays and you can't handle

delays so the best way to solve the

problem is get rid of the

delay and bring it back into the now

through Little Steps break all long-term

projects into baby steps do a baby step

a day you get there and if you don't do

that they're not doing it you have to

make motivation external they can't

create internal motivation they are

dependent on the environment for their

motivation you must put the consequences

in the now or they will not work for you

this is what video games do and what

homework does not which is why they can

play video games for hours and not do

their homework for more than a few

minutes video Gam games provide external

continuous reinforcement homework does

nothing video games do not need ex or

internal motivation whereas homework

does so you've got to create motivation

you're going to start to have to make a

deal with your kids what's in it for

them what are you putting in it for them

what are you creating what's the reward

what's the points what's the token

What's the sex the drugs and the money

whatever it is you're going to have to

negotiate a deal there has to be a

consequence or it isn't going to get

done

you have to make problem solving manual

remember they cannot do mental

manipulations like other people this is

why they can't do digit span backward

but it has nothing to do with digit span

they can't hold things in mind and move

them around as well as other people so

don't make them do it put it in their

hands if they have a math problem to

solve give them marbles a number line

and a Backus a calculator let them do

the problem manually or at least assists

the mental problem solving with manual

pieces to it it's the principle that

matters people you can come up with lots

of ideas here and then finally and this

is the most

important the executive system has a

limited fuel tank and you can spend it

out real quick every time you use an

executive function and you use it

continuously you empty the

tank and if you get to the bottom of the

tank in the next situation you will have

no self-control this is the ADHD child

after school gone and you want to do

homework you're out of your mind

so you got to refuel that tank and that

tank has a very limited capacity so how

do we refuel the tank interesting there

are lots of things we have discovered to

boost the tank the use of rewards and

positive emotions the use of self-

statements of Effectiveness I can do

this I know I can do this this is the

locker room pep talk before the game

helps to boost motivation in addition to

that you need to take 10-minute breaks

very often indeed more often you need to

break pass down into smaller units and

take frequent breaks and during those

breaks a little relaxation and

meditation helps to refuel the tank stop

using the executive system for a few

minutes and give it a chance to restore

its fuel tank this is why we talk about

the 10 and three rule with ADHD children

10 minutes of work three minute break 10

and three 10 and three but you can't do

more than 10 you're starting to empty

the tank give them a chance to refuel

the tank what does it say about keeping

Kids In For Recess when they don't get

all their homework done you just shot

yourself in the

foot and that leads me to the next thing

visualizing and talking about the future

rewards will help you boost the tank and

so does physical exercise routine

aerobic exercise boosts the tank refuels

it and creates a bigger tank everybody

with ADHD should be involved in an

exercise program because research shows

it benefits this disorder better than

any other psychiatric disorder and now

you know why it's helps to refuel that

tank and finally the fuel in the tank is

sugar in the bloodstream in the frontal

lobe blood glucose in the frontal lobe

is directly correlated with executive

abilities what does that mean if you

have an extensive task involving your

executive brain like an exam that you

have to do you better be sipping on some

lemonade or a Gatorade or a sports drink

sipping not gulping right you're going

to have to keep your blood sugar way up

so that you keep this fuel tank

partially restored so this is the

opposite of what people once thought

sugar hurts people with ADHD no it does

not and never did but it may well help

them if it's in fluid form that can get

into the brain very quickly you got to

keep that blood glucose up those are the

things you can do to boost the fuel tank

there are various approaches on the

market for adults and college students

with ADHD that incorporate these ideas

Steve's or Russ Ramsey's program which

is cognitive behavioral therapy does a

pretty good job of it I'm not going to

go through this with you Steve saffron's

program even better because it's based

on this model of executive functioning

so Steve talks about what you can do to

boost executive functioning in adults

who are on medication but they have to

be on medication and the most recent one

came out this March it is the most

heavily executive in nature it is Mary

Santo's program for training executive

functioning in adults with ADHD these

are the three tested programs that have

been shown to boost medication effects

in adults with ADHD and all of them

Target those deficits in the executive

brain as part of their models so what

have you learned today you've learned

that ADHD is not an attention disorder

you've learned that it's an executive

disorder that the executive system is a

very complex multi-level system like

driving it is not one level of cognition

and that's all it is it's multi-level

it's complex and it extends into our

daily life you know that ADHD disrupts

that system through behavioral

Innovation and wiping out all the other

executive abilities which puts you at

risk for failing in your executive

activities in your daily life people

with ADHD have problems in all

dimensions of executive functioning in

their daily life and that is going to

lead them to have great difficulty in

getting along with other people building

up friendships networks cooperatives

subordinating their interest to others

all the things in that involve executive

functioning from money management to

driving to friendships to families and

so on are at grave risk in this disorder

because they all depend on this

executive system so we are going to have

to help people with ADHD build the

scaffolding around them and use the

medication as neurogenetic therapy with

them in order to compensate for these

executive deficits we're going to have

to design prosthetic environments around

them you know the beauty of ADHD is it's

the most treatable dis disorder in

Psychiatry there is no disorder that we

treat that has as many medications and

as many psychosocial treatments that are

as effective as these are for as many

people producing more change than any

other medications and psychosocial

treatments for these individuals do you

know that 55% of people on medication

are normalized 90% of them respond do

you know that the effects of ADHD

medications are three times that of

anxiety drugs and anti-depressants that

you all give away like candy in your

practice

we have huge effective drugs on our

hands here that we can use and we also

have very effective psychosocial

interventions this is the most treatable

disorder that we Face the biggest

problem is most people don't get

treatment 40% of children and 90% of

adults with adht are not recognized or

treated for their disorder that's the

problem not that we're overtreating we

are undertreating and we're

undertreating the most treatable

disorder in Psychiatry thank you

welcome you are

welcome right on time shall I close the

fire

hydrant I know you're all going no more

no more I can't take it there's too much

information right luckily this will be

on the internet so you need to go back

and review it and you have your handouts

as well so we are going to proceed with

questions now we've collected your

questions we've sorted them into

categories we've weeded out redundancy

also these cannot be personal questions

because that's unethical so we're going

to try to keep them on the topic and not

about a person and they're going to read

them to me right so wrong pile Oh okay

wrong pile as Dr bar said