Transcription
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 interventions 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, do-its. 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 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 we'll 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 games provide external continuous reinforcement. Homework does nothing. Video games do not need external 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 assist 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 tasks 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 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 interests to others, all the things 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 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 antidepressants 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 ADHD 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. 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. Barr said.