This is how you treat ADHD based off science, Dr Russell Barkley part of 2012 Burnett Lecture
Summary
TLDRThe 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
- π§ ADHD is primarily a performance disorder, not a knowledge disorder. People with ADHD know what to do but struggle to execute it.
- π°οΈ ADHD causes 'time blindness', making it difficult for individuals to plan and aim their behavior towards the future.
- π« 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'.
- π 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.
- π€ΈββοΈ Executive function training alone is not sufficient. The environment needs to be engineered to support individuals in demonstrating their knowledge.
- π Accountability needs to be tightened for those with ADHD, bringing consequences closer in time to address the issue of delayed consequences.
- π Making mental information physical through cues, signs, charts, and reminders can help externalize information and support those with ADHD.
- β³ 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.
- π Breaking down lengthy assignments into smaller, manageable steps can make tasks more achievable and reduce the impact of delays.
- ποΈββοΈ Physical exercise and maintaining high blood sugar levels through proper nutrition can boost the executive function 'fuel tank'.
- 𧩠Using tangible, hands-on tools to assist with problem-solving can be beneficial for those with ADHD who struggle with mental manipulation.
- π 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
π§ 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.
π οΈ 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.
π 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.
Mindmap
Keywords
π‘ADHD
π‘Executive Functions
π‘Performance Disorder
π‘Neurogenetic Deficits
π‘Scaffolding
π‘Accountability
π‘Externalizing Information
π‘Blood Glucose
π‘Medication
π‘Psychosocial Treatments
π‘Time Blindness
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
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