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Title: ADHD: Essential Ideas for Parents – Dr. Russell Barkely
Duration: 02:51:43
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[Music]
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[Applause]
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[Music]
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when Heidi asked me to come up uh to
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speak to you an invitation by the way
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for which I'm grateful and honored the I
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thought what am I going to say to what
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is largely I believe a group of parents
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and loved ones of people with ADHD and
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and so she wanted me to do something a
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little new and a little different and I
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sat down and I said you know what ideas
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would I want any family that we had seen
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in our Clinic to understand by the time
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we had finished working with that family
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by the time we'd finished the evaluation
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and the counseling of that family what
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what would be the 30 take-home ideas I
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tried to reduce it to 10 by the way but
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that's just not possible and 30 was even
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a bit of a struggle there's another 30 I
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left out but I I think of these as sort
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of the Touchstone ideas that a family
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needs to understand if they really are
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going to appreciate the both the nature
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of this disorder in a child and what it
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means for the raising and management of
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that child
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successfully so we're going to have some
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fun with this because I've not done this
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presentation in this way ever before and
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you may advise me never to do it again
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so we'll see obviously the first idea is
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to know the disorder and we begin at a
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very Elementary stage of this disorder
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this is a developmental
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disability that is the first thing you
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need to understand a disability of what
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there are two psychological traits that
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are not developing in this child on
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time so let's clarify that a
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developmental disability means that you
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are showing age inappropriate behavior
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it doesn't mean that your behavior is
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pathological it just means it's not
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appropriate for your age
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so understand one thing ADHD is
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different from normal in a quantitative
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way not a qualitative way developmental
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disorders differ from
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psychopathologies a Psychopathology is a
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gross aberration in your behavior that
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we can recognize at any age if you are
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bipolar if you are schizophrenic if you
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have major depression we don't need to
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adjust the criteria for your age
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because those are grossly abnormal
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conditions autism would be another one
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those are not developmental disabilities
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a developmental disability is a delay in
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the rate of a normal
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trait what distinguishes this child from
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other children who don't have the
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disorder is the degree of the delay they
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will go through the same stages that
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others would go through in normal
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development but not at the same time and
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when these traits reach their ultimate
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maturity which by the way is your early
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30s the person with ADHD will be
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leveling off at a degree well behind
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that of where the general population has
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leveled off in that trait so delay does
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not mean lag it doesn't mean temporary
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this is a chronic lag in the development
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of these traits but the important thing
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is that the difference between this
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child and other children is quantitative
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it is like someone sitting next to you
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who is shorter or taller it is like
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someone who is more athletic or less
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athletic these are not qualitative
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differences they're
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quantitative so that is what separates
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your child from others the degree of the
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delay is the distinction I say this
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because so many trade books written for
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parents have argued that ADHD is a
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qualitatively different human your child
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is a little Hunter and he has to go to
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school with
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Farmers your child has a gift that other
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children do not have this is nonsense
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this is utter gibberish they're never
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was nor will be any science that would
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support those ideas ADHD is not a
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qualitative different state of humanity
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from other people it is much more like
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being better or worse at writing taller
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or shorter in your height better or
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worse at language those are quantitative
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differences that's important because
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otherwise we stigmatize these people as
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coming from a different planet you know
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one is from Venus another from Mars to
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uh popularize or to take up a popular
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view of gender differences between men
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and women but you get the point people
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with ADHD are not different from normal
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other than in the degree of the delay
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now what is it that is
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delayed two traits the first is not the
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one after which the disorder is named in
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that sense the disorder has been
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misnamed the first deficit to appear is
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inhibition a failure to develop it
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appropriate inhibition of your behavior
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and this will often emerge in the
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preschool years and its first sign is
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usually hyperactivity though it doesn't
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need to be so but it typically is you
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have an individual who is behaving too
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much who is not suppressing irrelevant
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Behavior the way other children are able
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to do we will see this in their motor
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actions there's a lot of action coming
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out of this CH we will see it in their
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verbal Behavior there's a lot of words
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coming out of this
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individual and we will see it in their
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intrusive and disruptive motor and
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verbal Behavior as well but along with
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that there is a cognitive impulsiveness
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this snap decisionmaking this quick
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wickness to do the first thing that pops
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into your head without due delay and due
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diligence thinking about what the
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consequences will
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be and then we will also see the
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restlessness not just the gross motor
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activity but the seat restlessness which
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I think affects their school performance
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more than the gross motor activity does
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but this will decline with age so that
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is why hyperactivity is no longer the
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name of this disorder because it
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declined steeply and by adolescence it's
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nearly gone and by adulthood it's an
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internal State it's a feeling inwardly
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of a need to be busy in doing multiple
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things and it's a busyness of one's mind
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one's ideas there was a Restless quality
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to their
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cognition but not to their outward
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behavior in fact our research has shown
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that hyperactivity is of no diagnostic
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value in adulthood in fact being
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Restless is more associated with anxiety
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disorders by the time you're 30 than it
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is being associated with ADHD we just
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don't pay attention to it it's of no
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relevance to
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diagnosis so let's understand that the
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real problem here is not restlessness it
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is in fact inhibition there is a failure
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to develop appropriate inhibition and it
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affects your behavior it affects your
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words it affects your mind and your
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thoughts and we need to return to the
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idea which which we have gotten rid of
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that it affects your emotions for the
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first 170 years of the history of ADHD
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in the medical literature which began in
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1798 not
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1902 8 years ago the last remaining copy
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of a medical textbook was discovered at
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Kent State
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University this textbook was written by
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the Scottish physician then living in
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colonial America Alexander kryon and
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kryon had written a medical textbook in
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which there is a chapter entitled
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diseases of attention and it is the
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first description of this disorder and
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it's very good by the
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way so ADHD did not begin in 1902 it
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started in 1798 as far as the first
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initial medical reference and from that
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point on until
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1976 emotion was part of
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ADHD every major theorist every paper
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every science paper including that of
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Mark Stewart one of the first major
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scientific descriptions the Canadian
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papers by Weiss and Heckman and warry
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and Douglas and others back in the 60s
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and 70s all included emotional
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impulsiveness as part of this
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disorder but the DSM parsed it aside and
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made it an Associated problem in some
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people it isn't it is as much a core
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feature of this disorder as is any other
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syp symptom in the DSM and that was our
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mistake and it needs to be returned to
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our understanding of
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ADHD by emotional impulsiveness I mean
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this quickness to anger to be easily
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excitable to have low frustration
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tolerance to be easily angered by things
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around you and to display your emotions
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much more quickly than other people do
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now this is not a mood disorder even
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though it starts to look like one mood
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disorders are where you are gen erating
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too much emotion what ADHD is is a
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failure to regulate normal emotion it is
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a self-regulation disorder the feeling
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you're having is normal that you are not
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moderating it is not it is this
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inability to self soothe to
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self-calm and to then moderate the
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emotion to be more acceptable for the
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context and for what you hope to
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accomplish here the goal that is at hand
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your long-term welfare is at stake can
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you modify that emotion to be more
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socially acceptable to be less costly
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less
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damaging that is as much a part of ADHD
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as anything else and we are pushing the
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dsm5 Committees there are several to
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reincorporate emotional impulsiveness
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and this emotional
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disregulation as being a part of this
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disorder because it loads on this
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dimension
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you cannot be impulsive in your behavior
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and not be impulsive in your emotions
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that is impossible because they are a
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Unity they go
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together emotion is welded to everything
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you say and do sometimes it is benign
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and Bland other times it is powerful and
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intense it is the emotional coloring of
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the behavior we display if you are
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impulsive in one you must be in the
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other that needs to get re introduced
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back into ADHD for a number of
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compelling reasons not just because
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historically it was always there but
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because it explains so much more than
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the current view of ADHD explains as I
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will show you ADHD children are 11 times
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more likely to develop Oppositional
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Defiant Disorder within 2 years of the
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onset of their ADHD why what are those
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disorders have to do with each other now
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they're treated as simply comorbidity oh
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well they go together but we're not not
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sure but if you put emotion back into
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ADHD you see the connection right into
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OD because everybody with ADHD is
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automatically subclinically OD at the
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get-go it's only going to take one more
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symptom to cross the diagnostic
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threshold in other words ADHD causes
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OD that is an important thing to
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understand because the OD while it does
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have some social influences over it half
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of OD is the inability to manage
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frustration impatience and anger and
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that will set you up for the second
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component of OD which is interaction
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conflict Defiance arguing but the first
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four symptoms of the eight in od are
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mood anger temper hostility easily
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annoyed irritability and that is part of
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ADHD so so we need dsm5 and we need
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families to both understand that emotion
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goes with this disorder it is not a
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separate comorbidity in some cases and
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now we know why when we treat ADHD
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particularly with the medications that
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we use we get nearly as much reduction
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in od as we get in ADHD and when we
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don't it is because of the social
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conflict component which is
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learned and we will have to unlearn that
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little piece but the mood component is
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the ADHD component Now by returning
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emotion into ADHD it also helps families
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to understand some of the other life
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course risks 50 to 70% of ADHD children
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are utterly rejected by close
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friendships by second
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grade it is in fact one of the more
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devastating consequences of this
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disorder is this inability to make and
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keep close sustained friendships with
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others their children and it is
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heartbreaking for parents to see this
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happening that their child is not as
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liked as other children that the
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sleepovers the going to the movies and
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the other social events in which other
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children celebrate their peer
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relationships are shut off for this
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child why is it there the single best
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predictor of peer rejection is that
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symptom the emotional impulsiveness
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friends forgive you your distractability
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your forgetfulness your working memory
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problems and even your restlessness they
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will not forgive your anger your
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hostility the quickness with which you
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emote to other people because it is
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offensive it is socially costly so now
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we can begin to understand the numerous
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social problems that ADHD children are
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prone to because it arises from this
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aspect of the inhibitory deficit there
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are other things that it explains I
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could do a whole hour and a half as I
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did a month ago in Toronto on the
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importance of emotion in ADHD I won't go
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there but suffice to say that it
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explains the road rage during driving
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the job dismissals which are not the
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result of inattentiveness but of being
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too quick to anger too quick to express
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raw emotion in the workplace of which
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employers are not tolerant especially if
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it occurs with a
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customer and it also explains to us the
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marital difficulties and the parenting
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difficulties these children may be prone
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to because the single best predictor of
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marital problems in the adult with ADHD
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is not distractability it is
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emotion so we can begin to paint a
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better picture of understanding ADHD and
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its life course risks by understanding
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the nature of the inhibitory problem and
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that it includes emotion as part of it
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and that's just slide one I've got 85
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slides do you see why I'm
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concerned 15 minutes to do a slide all
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right so we better get rolling here but
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I thought you ought to know where we're
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going and by the way in case you hadn't
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noticed I will not talk down to you
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today I will treat you as if you were my
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colleagues my students my peers because
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I think that parents attend these things
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to learn and that's not going to happen
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if I have to dumb this material down and
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it is also insulting and I won't insult
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your intelligence either you're
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knowledgeable people I'll speak to you
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frankly using the scientific
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terminology
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[Music]
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please the second dimension failing to
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develop on schedule will appear about 2
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to 3 years after the first and this is
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known as the attention deficit but it
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isn't
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here again we have a
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misnomer there are at least six or seven
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kinds of attention and supporting
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networks in the human brain they are not
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all disrupted by this disorder what we
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want to know is which one to help us
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with differential diagnosis to help us
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tell ADHD from an anxiety disorder and
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from autism and all the other
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psychiatric disorders which all
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interfere with attention at some point
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in life ADHD is not the only attention
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deficit we need need to be more precise
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if someone comes to us and says my child
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or I am inattentive that is useless
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diagnostically what I need to know is
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the nature of the inattentiveness and we
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have now known for a decade that the
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inattentiveness that we see in ADHD is
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distinct from that produced by all other
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disorders because it is most I think
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accurately described as a failure of
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persistence the first attention problem
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is persistence toward a goal notice that
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this implies Behavior motivation and the
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future that is very important the other
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forms of attention do not ADHD is not a
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problem of perception of filtering of
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processing of how the posterior part of
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our brain functions it is a problem with
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the motor part of the brain this frontal
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lobe can you sustain action toward a
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goal adequately to attain it that
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implies a motivation deficit and that is
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true and it implies future directed
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behavior and that is true ADHD is a
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failure to direct Behavior forward in
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time we cannot persist toward these
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delayed end points in life the tasks the
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goals the things that need to get done
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so persistence is deficit one in the
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area of attention now to persist toward
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a goal you must be able to resist
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distractions but that too is not a
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perceptual issue it is a motor issue the
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person with ADHD does not have problems
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with perceiving distractors better than
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others it is that they respond to
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distractors more than others and that is
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an inhibitory failure not a perceptual
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difference you and I may all hear the
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noise in the kitchen the person with
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ADHD is compelled to react to it oh did
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you hear that I guess they're watch in
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dishes maybe I'll stop in and and take a
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look did you know I was a dishwasher
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when I was back in college that's how I
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earn my weight do you see what's going
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on here you all heard the dish but it
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was irrelevant to what we're here to do
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today but to the ADHD individual the
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distraction is going to provoke a
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response and the response can't be
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inhibited and now they're Off to the
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Races skipping from one thing to another
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to another now there is a third aspect
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here that is impaired but it it is not
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one of
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attention most people when they are
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distracted re-engage the incompleted
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goal the person with ADHD is far less
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likely to do so and this has nothing to
(00:19:40)
do with attention this is working
(00:19:43)
memory so I would want a family to
(00:19:46)
understand that there's more here than
(00:19:48)
inattentiveness there was a working
(00:19:50)
memory disorder and I would want them to
(00:19:52)
know that working memory is one of the
(00:19:54)
five special executive functions of the
(00:19:57)
human brain suggesting that ADHD is
(00:20:02)
efdd executive function deficit disorder
(00:20:05)
because working memory is where we
(00:20:07)
remember what we're doing it is
(00:20:09)
remembering so as to do it is
(00:20:11)
consciously effortfully holding in mind
(00:20:14)
the what the when of what we are
(00:20:18)
doing it's what you lose at my age and
(00:20:21)
when you hit
(00:20:23)
menopause you do not lose memory you
(00:20:27)
lose working memory you forget what you
(00:20:30)
were doing where you were going what the
(00:20:33)
goal was the steps to the goal how you
(00:20:36)
were getting there it is that that
(00:20:38)
allows you to re-engage the incompleted
(00:20:41)
goal because you are holding in mind the
(00:20:43)
goal it is that which ADHD children and
(00:20:46)
adults will lose the goal is gone it is
(00:20:49)
forgotten and now anything else
(00:20:51)
compelling around them will capture
(00:20:53)
their behavior hence the symptom Skips
(00:20:56)
from one incompleted activity to another
(00:21:00)
the ability to re-engage a goal is a
(00:21:02)
working memory
(00:21:03)
disorder and that's what they cannot do
(00:21:06)
and this begins to open the door on the
(00:21:08)
possibility that the other four
(00:21:10)
executive functions are impaired as well
(00:21:13)
more on that later so let's understand
(00:21:15)
that there are three interacting
(00:21:17)
attentional problems but that they are
(00:21:19)
best thought of as executive deficits
(00:21:22)
not attention deficits and they are the
(00:21:25)
problem with persistence toward the
(00:21:27)
future resistance of distractions along
(00:21:30)
the way and working memory and now you
(00:21:34)
understand the nature of this attention
(00:21:36)
problem from the one that's produced by
(00:21:38)
anxiety and depression and autism and
(00:21:41)
all the other disorders including the
(00:21:42)
learning disabilities which have nothing
(00:21:44)
to do with
(00:21:46)
these I would want families to
(00:21:49)
understand that there is more to
(00:21:51)
ADHD than just the inhibition and these
(00:21:55)
attention and working memory problems
(00:21:57)
that at its heart in its Soul it is a
(00:22:01)
disorder of
(00:22:02)
self-regulation not one of attention I
(00:22:05)
think the biggest problem we have had as
(00:22:07)
a group in convincing the general public
(00:22:09)
about the seriousness of our children's
(00:22:11)
disorder versus autism or schizophrenia
(00:22:15)
or the other disorders is the very name
(00:22:17)
itself is Trivial
(00:22:20)
ADHD go to Starbucks good God have some
(00:22:23)
caffeine we got more serious fish to fry
(00:22:25)
here in Psychiatry than the fact that
(00:22:27)
you just can't pay attention
(00:22:29)
right part of the reason that our
(00:22:32)
disorder that the name of this disorder
(00:22:34)
is so often pillared in the media is
(00:22:37)
because I think we misnamed it right
(00:22:39)
this is a developmental disorder of
(00:22:42)
self-regulation not of attention and
(00:22:44)
that is a serious disorder as serious as
(00:22:48)
manic depression and in its own way as
(00:22:52)
autism but it doesn't convey that to
(00:22:54)
people if they understand it only as a d
(00:23:00)
HD as opposed to
(00:23:03)
srdd a
(00:23:04)
self-regulatory developmental Disorder
(00:23:07)
so I would want families to understand
(00:23:09)
the seriousness of
(00:23:11)
this that this isn't simply in attention
(00:23:15)
there are some profoundly unique human
(00:23:17)
traits that are not emerging as they
(00:23:20)
should in this individual and if you'll
(00:23:23)
understand that you'll understand the
(00:23:25)
bigger picture the why of everything if
(00:23:28)
it's just an attention problem why am I
(00:23:29)
seeing impairments in virtually every
(00:23:31)
domain in which this child is asked to
(00:23:34)
function that would not come from just
(00:23:36)
inattentiveness but it would come from
(00:23:38)
an executive function disorder a
(00:23:41)
self-regulatory disorder so I would want
(00:23:44)
parents to understand that this is the
(00:23:46)
essence of this disorder
(00:23:49)
self-regulation what is that it is first
(00:23:51)
of all the ability to consciously
(00:23:55)
willfully choose to inhibit your
(00:23:58)
behavior
(00:23:59)
and then to engage in a series of
(00:24:02)
self-directed actions that is after all
(00:24:04)
what self-control is you start to do
(00:24:07)
things to
(00:24:09)
yourself these are responses that are
(00:24:11)
not directed at the world around you
(00:24:13)
they're directed at you right you're
(00:24:16)
trying to change your behavior in some
(00:24:18)
fundamental
(00:24:20)
way the second part of self-control that
(00:24:23)
your child struggles is not just the
(00:24:25)
stopping but the thinking the thinking
(00:24:29)
is the self-directed activity the stuff
(00:24:31)
I am doing to
(00:24:33)
myself why would I do these things to
(00:24:35)
myself to change my behavior from what
(00:24:38)
it would otherwise be and why would I do
(00:24:41)
that to change my future
(00:24:44)
self-regulation is not just for
(00:24:46)
short-term
(00:24:48)
self-improvement it's for long-term
(00:24:50)
self-improvement it's to see to your own
(00:24:53)
welfare over the long term should you
(00:24:57)
act this way give given the sustained or
(00:25:00)
delayed consequences that lie ahead for
(00:25:03)
you that is what you must stop and think
(00:25:05)
about and that is what they don't stop
(00:25:07)
and think about the delayed
(00:25:12)
consequences so your child is not just
(00:25:15)
inattentive they cannot stop and engage
(00:25:18)
in a series of self-directed actions
(00:25:22)
that they will now use to modify and
(00:25:25)
moderate their behavior so as to bring
(00:25:28)
it in line line with their long-term
(00:25:31)
welfare the future and that's what your
(00:25:34)
your child is struggling so mightily
(00:25:37)
with in their development it's what the
(00:25:39)
other kids are acquiring and your child
(00:25:42)
is so far behind
(00:25:52)
in I would want parents to understand
(00:25:54)
something that the vast majority of the
(00:25:56)
lay population does not understand
(00:25:59)
self-control is not
(00:26:02)
learned it is not the result of your
(00:26:05)
upbringing and how good your parents
(00:26:08)
were this is one of the most profound
(00:26:10)
insights from our research on
(00:26:12)
ADHD ADHD is we will see is largely a
(00:26:15)
neurogenetic disorder but then let's
(00:26:18)
pursue the implication if that is true
(00:26:20)
and ADHD is a self-regulation disorder
(00:26:22)
then self-control is largely
(00:26:24)
neurogenetic in origin that has a
(00:26:27)
philosophically Prof
(00:26:29)
conclusion the vast majority of
(00:26:31)
variation in the people sitting in this
(00:26:33)
room and their ability to manage their
(00:26:35)
behavior is not from how they were
(00:26:38)
raised it is a part of who they are it
(00:26:41)
is a part of their neurogenetic
(00:26:44)
gifts and that is very stunning
(00:26:48)
indeed that our capacity for regulating
(00:26:52)
ourselves is a neurobiological trait not
(00:26:56)
some socially learned phenomena that you
(00:26:59)
just happen to pick up from your
(00:27:01)
parents so I would want them to know
(00:27:04)
that
(00:27:05)
ADHD being a self-regulation disorder is
(00:27:08)
arising out of neurogenetic causes and
(00:27:12)
that this inability to direct Behavior
(00:27:14)
toward
(00:27:15)
yourself comes from impairments in the
(00:27:18)
following five executive abilities and
(00:27:21)
these have to do with brain development
(00:27:23)
not with training it does not mean that
(00:27:26)
training cannot enhance them it means
(00:27:29)
that they don't
(00:27:30)
originate at the
(00:27:32)
beginning in training in the social
(00:27:35)
environment the social environment
(00:27:38)
requires that they be there already and
(00:27:41)
then it will help to shape them to
(00:27:42)
become more proficient think of your
(00:27:45)
language ability you didn't learn
(00:27:47)
language but it doesn't mean that you
(00:27:49)
can't become more proficient in how you
(00:27:52)
speak and how you
(00:27:54)
write but speaking and writing are not
(00:27:57)
accounted for on the basis merely of
(00:27:59)
training by your parents you're going to
(00:28:01)
develop a language no matter where you
(00:28:03)
grow up that is a neurobiological trait
(00:28:07)
and it unfolds as the brain unfolds it
(00:28:09)
is an instinct and so is
(00:28:12)
self-control but self-control can be
(00:28:14)
reduced to these five things what are
(00:28:16)
the five things you do to yourself these
(00:28:19)
are the things your child struggles to
(00:28:20)
do number one can you stop can you wait
(00:28:26)
because as rabal said in the novel
(00:28:29)
Gargantua which most of you have never
(00:28:31)
read I'm sure but it is where this
(00:28:33)
phrase comes from everything comes to
(00:28:36)
those who can
(00:28:38)
wait the waiting is the tough part you
(00:28:41)
must build in a
(00:28:43)
pause between the event and what you
(00:28:47)
plan to do about it and in ADHD there is
(00:28:50)
no pause the event happens and your
(00:28:53)
response is up out done is as if there
(00:28:57)
was no front part to the brain
(00:28:59)
it is as if you were like any other
(00:29:01)
species with a spinal cord event
(00:29:03)
response event response or as an aary
(00:29:06)
Larson cartoon remember the far side two
(00:29:09)
amibas a husband and wife talking to
(00:29:11)
each other one amoeba the wife of course
(00:29:13)
says to her husband stimulus response
(00:29:15)
stimulus response don't you ever
(00:29:19)
think characterizes ADHD right there
(00:29:23)
don't you ever
(00:29:25)
think once you stop you will engage in
(00:29:28)
four subsequent actions the first is
(00:29:31)
mental imagery you will recall the past
(00:29:34)
and you will play a DVD of it in your
(00:29:36)
head you have a theater in your mind it
(00:29:39)
is your visual imagery
(00:29:41)
system the mind's eye so your child not
(00:29:45)
only cannot stop they cannot visualize
(00:29:47)
as well as other children and what they
(00:29:49)
do not visualize before they act is the
(00:29:52)
past the relevant
(00:29:55)
past do you have experiences in this
(00:29:58)
situation previously if so what would
(00:30:00)
they have told you to do lay people call
(00:30:03)
this hindsight and the word sight is no
(00:30:06)
coincidence you are visually imagining
(00:30:09)
your history what does it have to say
(00:30:13)
and you lack
(00:30:14)
hindsight now this will lead to
(00:30:17)
foresight you look back to
(00:30:20)
anticipate what does ADHD lead to no
(00:30:23)
foresight you are not thinking ahead
(00:30:26)
because you weren't looking back either
(00:30:28)
hindsight and foresight are the opposite
(00:30:31)
sides of the same coin visual
(00:30:34)
imagery so you will not use your images
(00:30:37)
of your past to tell you what to do you
(00:30:40)
will just do and then by 5 years of age
(00:30:44)
you will get the third executive deficit
(00:30:47)
you can't talk to
(00:30:49)
yourself young children by 5 years of
(00:30:51)
age are beginning to internalize their
(00:30:53)
speech and use it on themselves just
(00:30:56)
watch any first and second grade
(00:30:57)
classroom and you will see
(00:31:01)
this if you have a 3 to 5-year-old
(00:31:04)
you'll hear it they're talking to
(00:31:05)
themselves out loud most of the day
(00:31:07)
whether anyone is in the room or not
(00:31:09)
listen to bedtime and you will hear what
(00:31:11)
I mean but over the next 10 years this
(00:31:14)
external voice gets directed to
(00:31:16)
themselves and slowly made private and
(00:31:20)
mental in its form and so originates the
(00:31:23)
voice in your head and that voice in
(00:31:25)
your head is there for one very
(00:31:27)
important reason it's to help control
(00:31:29)
yourself you start telling yourself what
(00:31:32)
to do and it starts to work and now any
(00:31:35)
family I would explain this to would
(00:31:37)
understand that not only can your child
(00:31:38)
not stop not only do they not have the
(00:31:40)
Mind's Eye they don't have the mind's
(00:31:42)
voice and what is there is very weak
(00:31:46)
it's not controlling them so now you
(00:31:48)
know why they can't do what you tell
(00:31:49)
them to do they can't follow
(00:31:51)
instructions they can't follow rules
(00:31:53)
they can't internalize the rules of the
(00:31:54)
situation because everything I have just
(00:31:56)
said requires a voice in your head and
(00:32:00)
they don't have
(00:32:02)
that the next comes from the first three
(00:32:05)
and that is the mind's heart the ability
(00:32:09)
to manage your emotions so that they are
(00:32:11)
more socially acceptable so that they
(00:32:14)
are consistent with your goals not
(00:32:18)
conflicting with your
(00:32:21)
welfare and so we will see the ADHD
(00:32:23)
child as we've already described them
(00:32:25)
easily frustrated quick to anger
(00:32:27)
impatient
(00:32:28)
and just overall more excitable and more
(00:32:31)
emotional than others but what gets lost
(00:32:34)
in this explanation is something more
(00:32:36)
fundamental our emotions are our
(00:32:41)
motivations if you cannot manage your
(00:32:44)
emotions you cannot manage your
(00:32:46)
motivation either because the fourth
(00:32:49)
executive ability is the source of
(00:32:52)
self-motivation self motivation is the
(00:32:54)
fuel tank for all future Direct Ed
(00:32:58)
Behavior there is no getting ready for
(00:33:01)
tomorrow if there is no self-
(00:33:03)
motivation so what is the ADHD child
(00:33:06)
lost here they cannot motivate
(00:33:08)
themselves what does that mean it means
(00:33:11)
that you will always be dependent on the
(00:33:13)
environment around you and its immediate
(00:33:17)
consequences for how hard and how long
(00:33:20)
you can work and if there are no
(00:33:22)
consequences in that context you cannot
(00:33:26)
work you cannot persist you will not get
(00:33:30)
it done the fourth executive ability now
(00:33:33)
explains to these parents why this child
(00:33:35)
can play video games for hours and
(00:33:38)
cannot do homework for more than a few
(00:33:40)
minutes because the video game provides
(00:33:43)
external continuous 100% consequences
(00:33:47)
for interacting with it and the homework
(00:33:50)
does nothing when a problem is solved on
(00:33:54)
a sheet of paper nothing happens
(00:33:58)
[Music]
(00:33:59)
the consequences are
(00:34:02)
delayed and therein lies the trouble so
(00:34:06)
the coral are of this is if you want to
(00:34:08)
see an ADHD person fail you put him in
(00:34:10)
any environment where there are no
(00:34:12)
consequences and I guarantee you
(00:34:14)
failure the work will not get done
(00:34:17)
because the person cannot self motivate
(00:34:19)
and this is not a choice and this is not
(00:34:21)
willful and this is not a child who just
(00:34:25)
could if they wished wake up tomorrow
(00:34:27)
and smell the coffee and get busy and do
(00:34:28)
the work they cannot this is an internal
(00:34:32)
neurogenetic executive failure you can't
(00:34:36)
self-motivate like other people so it
(00:34:38)
doesn't matter what your goals are you
(00:34:39)
won't get
(00:34:40)
there because self motivation is
(00:34:43)
required for all goal directed
(00:34:46)
action the final executive ability which
(00:34:48)
will not emerge until late childhood in
(00:34:51)
the person with ADHD is the mind's
(00:34:53)
playground this is the ability to plan
(00:34:55)
and problem solve how many different
(00:34:58)
possible options can you generate right
(00:35:00)
now to get around this
(00:35:03)
problem this ability to simulate
(00:35:06)
multiple possible future
(00:35:09)
options is the highest executive
(00:35:11)
function in humans it is the source of
(00:35:14)
all cultural
(00:35:15)
Innovation but it originates in problem
(00:35:18)
solving how quickly in your mind can you
(00:35:22)
think of multiple ways to overcome the
(00:35:25)
problem you just encountered and people
(00:35:27)
with ADHD will struggle with this one as
(00:35:30)
much as with the
(00:35:31)
others so if you want to understand ADHD
(00:35:34)
as a parent you have got to understand
(00:35:36)
these are the five things that are
(00:35:38)
delayed in this child the ability to
(00:35:41)
stop to use visual imagery to use your
(00:35:44)
mind's voice to use your mind's heart
(00:35:47)
and emotion and motivation and when
(00:35:49)
called upon to do so to simulate
(00:35:52)
multiple possibilities when faced with a
(00:35:55)
problem or when planning out what you
(00:35:58)
hope to do planning and problem solving
(00:36:01)
those are the five executive abilities
(00:36:03)
we know where they are in the frontal
(00:36:04)
lobe we know that ADHD children have
(00:36:06)
lost all five of
(00:36:08)
them actually that's a bit of an
(00:36:10)
overstatement it's not that they don't
(00:36:12)
have them it's that they are quite
(00:36:14)
delayed and we will discuss the delay in
(00:36:16)
a moment so ADHD leads you to act on
(00:36:20)
impulse not resist distraction you are
(00:36:23)
less able to think back about what you
(00:36:25)
are doing about the action that lies
(00:36:27)
ahead you cannot use your hindsight and
(00:36:29)
therefore your foresight is gone you do
(00:36:31)
not plan ahead you live in the
(00:36:34)
moment this is going to rob you of your
(00:36:37)
sense of time because the sense of time
(00:36:39)
comes from looking back to look ahead
(00:36:42)
looking across time and knowing where
(00:36:44)
I'm going you will not have a subjective
(00:36:46)
sense of time and that alone is going to
(00:36:49)
be a devastating adult disability you
(00:36:52)
have the consummate disorder of time
(00:36:54)
management it's no wonder they're always
(00:36:57)
late you will not be able to talk to
(00:36:59)
yourself to reason with yourself to ask
(00:37:00)
yourself questions and to remind
(00:37:02)
yourself of the rules that are governing
(00:37:04)
the immediate situation and therefore it
(00:37:07)
doesn't matter what people say to you
(00:37:08)
over and over and over again you won't
(00:37:10)
do it no amount of ning by your teacher
(00:37:14)
or your mother will overcome the
(00:37:17)
internal mind's voice
(00:37:20)
deficit you will not be able to use
(00:37:22)
language as well as other people to
(00:37:23)
regulate
(00:37:24)
yourself and that is going to also lead
(00:37:27)
you to have a self self motivation
(00:37:29)
problem and a problem with regulating
(00:37:30)
your emotions and with self- soothing
(00:37:33)
when you do become emotional and then as
(00:37:36)
we've said you will have trouble with
(00:37:37)
planning and problem solving so if you
(00:37:39)
want to know the symptom list of ADHD
(00:37:41)
this is it the DSM is but a mere
(00:37:44)
superficial reflection of the most
(00:37:47)
obvious symptoms of these five executive
(00:37:50)
deficits but to truly understand ADHD
(00:37:53)
you need to know that these five are all
(00:37:55)
there underneath
(00:37:58)
to refer to ADHD as inattention is to
(00:38:00)
refer to autism as hand flapping and
(00:38:03)
speaking
(00:38:03)
funny they are the most obvious symptoms
(00:38:06)
of a failure to develop the ability to
(00:38:09)
relate to others as special objects as
(00:38:12)
humans and that is what autism really is
(00:38:15)
underneath the rest of it is just the
(00:38:17)
most superficial set of symptoms so I
(00:38:21)
would want my family to understand the
(00:38:24)
profundity of these deficits because in
(00:38:27)
a ition hardly captures what is going
(00:38:31)
wrong in
(00:38:32)
development now the DSM says there are
(00:38:35)
three kinds of ADHD let's shift gears
(00:38:37)
here and get honest there was not a
(00:38:39)
combined inattentive or hyperactive type
(00:38:43)
and dsm5 will abandon them they are
(00:38:46)
contaminated with each other because
(00:38:48)
there really is only a single ADHD in
(00:38:51)
the human population and it varies in
(00:38:53)
its severity and all these types have
(00:38:55)
done is to capture the degree of
(00:38:57)
severity of a single Disorder so we are
(00:39:00)
now grappling for ways of subgrouping
(00:39:03)
people with ADHD that is more clinically
(00:39:06)
useful than the DSM view is because the
(00:39:09)
DSM view is
(00:39:11)
useless and one of those ways that is
(00:39:14)
very compelling is ADHD with and without
(00:39:17)
conduct disorder the Europeans have done
(00:39:19)
this for decades in the North American
(00:39:22)
continent we viewed conduct disorder as
(00:39:25)
a comorbidity we are now looking at it
(00:39:27)
as a
(00:39:28)
subgrouping
(00:39:30)
criteria because you see ADHD children
(00:39:33)
who have conduct disorder differ from
(00:39:36)
ADHD children without it in many many
(00:39:39)
respects so many in fact that we are now
(00:39:41)
coming to think of this subset of
(00:39:42)
children who have both disorders as a
(00:39:44)
unique form of ADHD because both
(00:39:48)
disorders are more severe both disorders
(00:39:50)
start earlier both disorders are far
(00:39:52)
more persistent and the combination of
(00:39:54)
these disorders will predict ongoing
(00:39:57)
difficulties with antisocial Behavior
(00:39:59)
into adulthood and just as important
(00:40:02)
these individuals carry a high risk for
(00:40:06)
psychopathy one in five of these
(00:40:08)
children is a budding psychopath a child
(00:40:11)
who lacks guilt conscience empathy and
(00:40:15)
remorse a child who is a
(00:40:18)
predator ADHD does not contribute to
(00:40:22)
psychopathy but ADHD with conduct
(00:40:24)
disorder is the single best predictor of
(00:40:27)
the psychopath that we know
(00:40:29)
of so in the future we may be making the
(00:40:33)
same distinction the Europeans have that
(00:40:35)
when conduct disorder and ADHD go
(00:40:37)
together we have an extraordinarily
(00:40:39)
virent disorder in case you're not
(00:40:42)
familiar with conduct disorder it is the
(00:40:43)
early appearance of lying stealing
(00:40:45)
fighting and praying on other children
(00:40:47)
in an instrumental way it is violating
(00:40:50)
the rights of other people for your own
(00:40:52)
gain and it manifests early as the lying
(00:40:56)
the stealing and the fighting but other
(00:40:57)
symptoms will develop thereafter the
(00:41:00)
hyperactive type of ADHD never existed
(00:41:02)
because 90% of all cases go on to get
(00:41:04)
the combined type within 3
(00:41:08)
years and even if they don't get the
(00:41:10)
combined type they're just one symptom
(00:41:12)
short and so we call them sub threshold
(00:41:15)
combined types but they're not a
(00:41:16)
different type so if we take these two
(00:41:18)
groups of children who really are just
(00:41:20)
variations on the good old combined type
(00:41:21)
of ADHD that's 95% of all the kids put
(00:41:24)
into this group there is a small group
(00:41:27)
left over who are purely oppositional
(00:41:29)
but because they have pure oppositional
(00:41:31)
disorder and they never had ADHD they
(00:41:33)
will outgrow their OD usually within 2
(00:41:35)
to four years and their ADHD will go
(00:41:39)
away why are they there because parents
(00:41:42)
confuse OD with ADHD and if their child
(00:41:45)
is only oppositional they often report
(00:41:46)
that they have symptoms of ADHD when
(00:41:48)
they don't but OD alone is a relatively
(00:41:52)
benign disorder unless it goes with ADHD
(00:41:55)
and that it is a highly persistent
(00:41:57)
disorder
(00:41:58)
now the real action during the past
(00:41:59)
decade has been with this inattentive
(00:42:01)
group of children most of whom are
(00:42:03)
combin type children and they grew up
(00:42:06)
and they lost some hyperactivity along
(00:42:07)
the way as we said and as a result
(00:42:09)
there's going to come a time in
(00:42:10)
adolescence and especially by adulthood
(00:42:12)
where they're just not hyperactive
(00:42:13)
enough to stay in the combin type
(00:42:15)
anymore and so clinicians relabel them
(00:42:17)
as inattentive type but they shouldn't
(00:42:19)
once combined type always combined type
(00:42:23)
but you can see how at least half of the
(00:42:25)
individuals get put into the inattentive
(00:42:26)
group they just out growing their
(00:42:28)
hyperactivity and then there's that
(00:42:30)
group of children who just are one or
(00:42:32)
two symptoms short of being in the
(00:42:34)
combined type but they have the combined
(00:42:36)
type anyway they're just a milder
(00:42:37)
version of it but
(00:42:39)
interestingly 30 to 50% of the children
(00:42:42)
who are now called inattentive type
(00:42:45)
probably have a different disorder and
(00:42:47)
researchers have called them
(00:42:50)
SCT it's about 30 to 50% of all
(00:42:53)
inattentive type children and we now
(00:42:55)
believe this is a qualitatively uni
(00:42:57)
unique disorder the debate now is
(00:43:00)
whether this is a separate type of ADHD
(00:43:03)
a point with which I
(00:43:06)
disagree or is it a qualitatively
(00:43:08)
separate disorder a point with which I
(00:43:12)
agree why would I view this as a
(00:43:14)
different
(00:43:15)
disorder first of all the symptoms are
(00:43:17)
the opposite of ADHD but you won't see
(00:43:20)
them anywhere in the DSM but these are
(00:43:22)
the most compelling symptoms that go
(00:43:23)
with
(00:43:24)
SCT but because these children also have
(00:43:27)
an attention problem there was no place
(00:43:29)
else to put them because ADHD is the
(00:43:31)
only attention disorder in the DSM so
(00:43:34)
they get dropped into ADHD even though
(00:43:36)
they have no symptoms in common with it
(00:43:40)
these individuals have a problem with
(00:43:42)
processing information which ADHD
(00:43:44)
children do not have these children have
(00:43:47)
trouble with focused attention choosing
(00:43:49)
what's important from what's not ADHD
(00:43:51)
children do not their problem is in
(00:43:53)
persistence these people may have a
(00:43:56)
long-term memory storage problem or it
(00:43:58)
could just be the same attention problem
(00:44:00)
that appears when they search their
(00:44:01)
memory what is quite distinct about them
(00:44:04)
is that they are socially
(00:44:05)
withdrawn reticent shy apprehensive and
(00:44:10)
often prone to social anxiety but
(00:44:12)
certainly socially reticent is a very
(00:44:15)
good word for them this is not a word
(00:44:17)
that would ever be applied to an ADHD
(00:44:21)
child most importantly and tellingly
(00:44:24)
they do not have an inhibition disorder
(00:44:25)
and inhibition is the heart of
(00:44:28)
ADHD and therefore they do not have a
(00:44:30)
self-regulation disorder and ADHD is a
(00:44:32)
self-regulation disorder and these
(00:44:35)
individuals do not have the executive
(00:44:37)
deficits that I just listed for you that
(00:44:39)
go with ADHD for those reasons alone you
(00:44:43)
could argue that this is a distinct
(00:44:45)
disorder but there are others there is a
(00:44:47)
very low rate of oppositional and
(00:44:48)
conduct disorder associated with this
(00:44:50)
type of child OD and CD are much more
(00:44:53)
common in ADHD children these children
(00:44:55)
have more anxiety problems
(00:44:58)
ADHD children while one in four may have
(00:45:00)
anxiety it's far higher in this group
(00:45:03)
we're not sure if depression goes with
(00:45:04)
this group both groups have about a 20
(00:45:06)
to 25% risk of depression but it doesn't
(00:45:09)
distinguish the two
(00:45:10)
disorders when we interview families of
(00:45:13)
these children their parents are
(00:45:14)
concerned only about
(00:45:16)
school nothing else these are good kids
(00:45:19)
not disruptive outside of school they
(00:45:21)
even have a few friends not as many as
(00:45:24)
other children but more than ADHD
(00:45:26)
children will ever
(00:45:28)
have so the big concern is let's get
(00:45:31)
that school work done and the mistakes
(00:45:33)
they're making in school you interview
(00:45:35)
the parent of an ADHD child they're
(00:45:36)
worried about
(00:45:38)
everything peer relationships family
(00:45:40)
functioning Community Behavior not to
(00:45:43)
mention what happens as the teen gets
(00:45:45)
older and starts driving and having a
(00:45:48)
job and managing money and becoming
(00:45:49)
sexually
(00:45:51)
active sat families don't worry about
(00:45:54)
any of that stuff ADHD families worry
(00:45:56)
and well they should
(00:45:58)
[Music]
(00:46:02)
these children mainly have trouble with
(00:46:04)
accuracy of schoolwork they get all
(00:46:06)
their work done and half of it's wrong
(00:46:09)
ADHD children don't do any
(00:46:13)
work so the
(00:46:15)
difference is an accuracy disorder ADHD
(00:46:19)
is a productivity disorder that's a
(00:46:21)
qualitative difference another one is
(00:46:23)
that these children may be more prone to
(00:46:24)
math disorders but we're not sure about
(00:46:26)
that these children come from quite
(00:46:28)
different families families with the
(00:46:30)
same kinds of problems higher rates of
(00:46:33)
anxiety higher rates of learning
(00:46:35)
problems in school that's about it
(00:46:38)
children with ADHD come from families
(00:46:40)
with a lot more ADHD a lot more school
(00:46:42)
failure a lot more antisocial Behavior
(00:46:46)
alcoholism depression and drug abuse
(00:46:50)
these children do not when we look at
(00:46:52)
the treatments that work for these
(00:46:53)
children and this has not been very well
(00:46:55)
studied by the way but even here
(00:46:57)
differences appear the medications for
(00:47:00)
ADHD don't work very well for these
(00:47:01)
children they don't hurt them you can
(00:47:03)
try them the lowest doses are the best
(00:47:06)
they just don't help them in fact in our
(00:47:07)
study only one in five children was kept
(00:47:09)
on their medication after the trial in
(00:47:12)
ADHD it's
(00:47:15)
92% these children are the best
(00:47:17)
responders to social skills training but
(00:47:18)
no surprise social skills training was
(00:47:20)
invented 40 years ago for shy people and
(00:47:23)
we know it works best for shy people not
(00:47:26)
for aggressive people
(00:47:28)
and so these children actually do very
(00:47:29)
well in social skills training ADHD
(00:47:32)
children do not do well at all in social
(00:47:34)
skills training if they do it needs to
(00:47:36)
be done in the school environment with
(00:47:38)
the children they go to school with not
(00:47:39)
in a summer camp and certainly not in
(00:47:41)
some Saturday morning Clinic with other
(00:47:44)
children they'll never see again the
(00:47:45)
rest of their life if you're doing that
(00:47:47)
you're probably wasting your
(00:47:49)
money so if they benefit it's because
(00:47:52)
they benefit by the teachers and others
(00:47:54)
doing the training outside of the clinic
(00:47:56)
environment in the natural setting where
(00:47:58)
the social problems arise and even then
(00:48:00)
it's not so much the skill training as
(00:48:02)
prompting and queuing and rewarding the
(00:48:05)
occurrence of the skill now do be aware
(00:48:07)
that research now shows that one in four
(00:48:09)
children put in a social skills group
(00:48:11)
will be made worse by the group this is
(00:48:13)
known as deviancy training and it
(00:48:14)
happens to occur because the more
(00:48:16)
aggressive children in any peer group
(00:48:19)
will train up the less aggressive
(00:48:20)
children to become more aggressive if
(00:48:23)
only in self-defense it happens every
(00:48:24)
kindergarten year to normal children as
(00:48:27)
well
(00:48:28)
so clinicians need to be careful because
(00:48:30)
there are side effects to social
(00:48:32)
interventions 25% of ADHD children get
(00:48:35)
worse by being in a social skills group
(00:48:37)
and we wish to avoid that now the MTA
(00:48:40)
study has found that anxiety is the best
(00:48:42)
predictor of response to the behavioral
(00:48:44)
interventions we could argue therefore
(00:48:46)
that children are probably the best
(00:48:48)
responders to behavior modification even
(00:48:50)
better than ADHD children are we know
(00:48:53)
that cognitive therapy which is teaching
(00:48:55)
children to talk to themselves
(00:48:57)
fails for ADHD we know why now because
(00:49:00)
the mind's voice is not developing on
(00:49:02)
time and in order for talking to
(00:49:04)
yourself to have any success you must
(00:49:07)
have a normally developing internal
(00:49:09)
speech and they don't at least not until
(00:49:12)
adulthood and then some cognitive
(00:49:14)
training does help as a supplement to
(00:49:16)
medication but in childhood cognitive
(00:49:19)
training doesn't help ADHD but this
(00:49:21)
isn't ADHD so shouldn't we revisit this
(00:49:25)
and do cognitive training for
(00:49:28)
no one has done it there's a
(00:49:30)
dissertation you know somebody who wants
(00:49:31)
a dissertation I just gave you
(00:49:35)
one what about medication well we don't
(00:49:38)
know we know the stimulants aren't
(00:49:40)
particularly wonderful for them they
(00:49:41)
don't hurt them but they don't help them
(00:49:42)
all that much what else might work well
(00:49:44)
I don't know honestly but let me
(00:49:46)
conjecture if I were writing a grant
(00:49:47)
tomorrow I might speculate that strua
(00:49:50)
might work for these children only
(00:49:52)
because these are more anxious children
(00:49:54)
and stratti treats anxiety when it
(00:49:56)
coexists with ad HD so maybe atomoxetine
(00:50:00)
might have a shot at this disorder we
(00:50:02)
don't know nobody's done it another drug
(00:50:05)
that might be interesting Is Provigil
(00:50:08)
mfil mafil is an
(00:50:10)
anti-narcotic and it does seem to help
(00:50:12)
people with ADHD it might help this
(00:50:14)
group even more because you remember
(00:50:16)
those symptoms I showed you two slides
(00:50:17)
ago does that sound a little narcoleptic
(00:50:20)
to you lethargic slow moving drowsy
(00:50:25)
staring inen
(00:50:28)
H maybe a brain stab drug might help you
(00:50:30)
again all speculative we don't know by
(00:50:34)
the way that is all we do know on Sat so
(00:50:36)
please don't ask me any more questions
(00:50:38)
about it cuz you now know everything I
(00:50:42)
know what I do want you to know as a
(00:50:44)
family is to understand that that's not
(00:50:46)
ADHD ADHD is quite different from that
(00:50:49)
and so if you happen to have an scct
(00:50:51)
child or you know someone who does
(00:50:53)
please don't tell them to read the books
(00:50:55)
on ADHD they will be sadly Mis informed
(00:50:58)
they will be told of all kinds of risks
(00:50:59)
and all kinds of treatments which as far
(00:51:01)
as we know have little if any
(00:51:02)
application to these children there is
(00:51:05)
no book for parents onct not yet nor
(00:51:07)
should there be we don't know enough but
(00:51:10)
researchers are now studying these
(00:51:11)
children the very first psychological
(00:51:14)
treatments for were published about a
(00:51:16)
year ago at the University of California
(00:51:19)
San Francisco and so we're now beginning
(00:51:22)
to see more and more research onct
(00:51:24)
children as distinct from ADHD children
(00:51:26)
but what I would want a family of an SE
(00:51:28)
child to understand is that this is an
(00:51:31)
ADHD so what you should be worried about
(00:51:34)
are not the things families of ADHD
(00:51:36)
children should be worried about it's
(00:51:38)
pretty much going to be a school-based
(00:51:40)
issue and the treatments that don't work
(00:51:42)
for those kids might well work for your
(00:51:44)
child and the treatments that do work
(00:51:46)
for those kids such as medication might
(00:51:48)
not be so great for your child no harm
(00:51:51)
but not necessarily so great
(00:51:59)
now the next point I'd like a family to
(00:52:01)
understand and we are only a number six
(00:52:04)
whoa 25 to
(00:52:08)
go that the deficits in these executive
(00:52:11)
abilities chiefly arise from problems
(00:52:13)
with brain development so we're going to
(00:52:15)
do a very quick three minute crash
(00:52:17)
course on
(00:52:19)
causation what causes
(00:52:22)
ADHD multiple things but all of them
(00:52:26)
follow into the realm of biology we now
(00:52:29)
know that you cannot turn a normal child
(00:52:31)
into an ADHD Child by exposing them to
(00:52:33)
any social influence it's not possible
(00:52:35)
not going to happen we also know that
(00:52:37)
these causes can interact with each
(00:52:39)
other I'll show you a slide on that very
(00:52:40)
interesting multiple biological hazards
(00:52:43)
may be interacting to produce the
(00:52:44)
disorder we now know where in the head
(00:52:46)
this is coming from so if someone tells
(00:52:49)
you we don't know where in the brain it
(00:52:50)
is they're wrong go to the library
(00:52:52)
please read a
(00:52:54)
journal we know that social factors
(00:52:57)
alone do not cause this disorder but
(00:52:59)
social factors are very important kindly
(00:53:01)
do not leave this room and say that Russ
(00:53:03)
said that social factors don't matter I
(00:53:05)
didn't say that I said they don't cause
(00:53:06)
it but they do matter in three important
(00:53:09)
ways first the resources you will have
(00:53:11)
available to treat this child are very
(00:53:13)
much a function of the social
(00:53:14)
environment around you second the
(00:53:17)
impairments your child will experience
(00:53:18)
are very much a part of the situation
(00:53:21)
you can rearrange environments so
(00:53:23)
they're less impairing third comorbidity
(00:53:27)
we know that other disorders that link
(00:53:28)
up with ADHD have some social
(00:53:30)
contributors to them oppositional
(00:53:32)
disorder conduct disorder anxiety
(00:53:35)
disorder and depression all have social
(00:53:38)
contributions indeed 40 to 50% of the
(00:53:41)
variation in those disorders is the
(00:53:43)
social
(00:53:44)
environment so while the social
(00:53:46)
environment doesn't cause this disorder
(00:53:49)
I would want families to understand that
(00:53:50)
doesn't mean it's not important or
(00:53:52)
irrelevant it's important for several
(00:53:54)
other very important reasons now we know
(00:53:58)
that a third of all ADHD is acquired not
(00:54:01)
genetic and that most of those acquired
(00:54:03)
cases occur during pregnancy and these
(00:54:06)
are the things that we have found that
(00:54:07)
are likely to cause ADHD in The Unborn
(00:54:10)
Child because all of these disrupt the
(00:54:13)
formation of the frontal lobe of the
(00:54:15)
brain but we also know that about 5% of
(00:54:17)
ADHD can occur after birth as a result
(00:54:20)
of various traumas and infections and
(00:54:23)
other things that can affect ongoing
(00:54:24)
brain development in these five Cru
(00:54:27)
areas and it is the acquired cases that
(00:54:30)
are most likely to have seizures we know
(00:54:32)
that lead
(00:54:33)
poisoning treating leukemia that's right
(00:54:35)
the treatments for leukemia can cause
(00:54:38)
ADHD we know that strep bacteria
(00:54:40)
contributes a small amount of ADHD why
(00:54:44)
would the strep bacteria do that because
(00:54:46)
the strep bacteria has a protein on the
(00:54:49)
outside of it and that protein is
(00:54:51)
identical to proteins that occur in the
(00:54:54)
brain and therefore your immune system
(00:54:56)
attacks your
(00:54:57)
brain so it's not the bacteria it's the
(00:55:00)
fact that the immune system can't
(00:55:02)
distinguish the bacteria from nerve
(00:55:04)
cells and this damages certain parts of
(00:55:06)
the brain and one of those parts causes
(00:55:08)
ADHD it's not a very common problem but
(00:55:10)
it can
(00:55:13)
happen we know the brain regions that
(00:55:15)
are giving rise to ADHD and we know that
(00:55:17)
in 2third of children the reasons for
(00:55:19)
these brain regions being smaller has to
(00:55:21)
do with genetics about which I will say
(00:55:23)
more in a moment but let's at least go
(00:55:24)
through these brain regions the five
(00:55:27)
regions of the brain that are
(00:55:28)
interconnected to each other and give
(00:55:29)
rise to this disorder are the right
(00:55:31)
frontal lobe right over here especially
(00:55:33)
over the
(00:55:34)
eyebrow and the connections from there
(00:55:36)
deep into the brain called the basal
(00:55:37)
ganglia I'll show it to you in a moment
(00:55:40)
and then there are connections from the
(00:55:41)
central part of the brain back to the
(00:55:43)
very primitive structure of the back of
(00:55:44)
the brain known as the cerebellum that
(00:55:46)
is also smaller and then there's a very
(00:55:49)
special part of the brain that lies
(00:55:51)
right between the eyes in the midline
(00:55:54)
going back on the walls of the two heav
(00:55:56)
hemispheres as they come together and
(00:55:59)
deep inside on those walls is the
(00:56:01)
anterior singulate and that is where the
(00:56:04)
emotional disregulation
(00:56:06)
originates finally there is the Corpus
(00:56:08)
colossum which allows the two
(00:56:09)
hemispheres to talk to each other but
(00:56:11)
it's no surprise the front part of the
(00:56:13)
brain is smaller then the Corpus Clum
(00:56:15)
has to be smaller the size of this
(00:56:17)
network is directly related to severity
(00:56:19)
of ADHD and in children who inherit the
(00:56:22)
disorder this these parts of the brain
(00:56:24)
are about 3 to 10% smaller that's it
(00:56:27)
just 3 to 10% doesn't sound like much
(00:56:29)
and it isn't but it's enough to cause
(00:56:31)
this disorder more importantly it's not
(00:56:35)
enough to use brain Imaging for
(00:56:37)
diagnosis these differences are so small
(00:56:39)
and so subtle that you could not use
(00:56:41)
them to classify people which is why no
(00:56:44)
brain Imaging technique including Dr
(00:56:47)
aiman's spec scanning is of any value
(00:56:50)
for
(00:56:52)
diagnosis we know that there are very
(00:56:54)
few gender differences in these networks
(00:56:56)
though there are some that are
(00:56:57)
interesting I won't talk about them
(00:56:58)
today and we know that these differences
(00:57:00)
are relatively persistent over
(00:57:03)
time the structural differences will
(00:57:05)
normalize by about 16 to 18 years of age
(00:57:08)
that is the size of the brain but the
(00:57:10)
functioning of the brain will
(00:57:12)
not and contrary to Tom Cruz and the
(00:57:15)
scientologists these brain differences
(00:57:16)
have nothing to do with giving
(00:57:18)
medication to these children so let me
(00:57:20)
show you the parts of the brain we're
(00:57:21)
talking about very quickly let me get my
(00:57:23)
cursor up here in the screen this is the
(00:57:25)
right orbital frontal area right
(00:57:28)
here this part of the brain projects
(00:57:31)
back in between those two hemispheres
(00:57:33)
there's a structure you can't see it's
(00:57:35)
right about in here and that's the
(00:57:36)
anterior singulate and then there are
(00:57:38)
projections back into the basal ganglia
(00:57:41)
right here and then back to the
(00:57:43)
cerebellum right there and it's the
(00:57:46)
right side of the cerebellum in the
(00:57:47)
central part that's smaller indeed most
(00:57:51)
interesting is that research has found
(00:57:52)
in the last 2 years that the parents and
(00:57:55)
the brothers and sisters have ADHD
(00:57:57)
children also have smaller neural
(00:57:59)
networks in exactly these areas except
(00:58:02)
for
(00:58:03)
one and that is the
(00:58:05)
cerebellum which tells us that of all of
(00:58:07)
these differences most of them are part
(00:58:09)
of the family phenotype even if the
(00:58:12)
family member never shows the disorder
(00:58:14)
they carry these patterns of
(00:58:17)
underdevelopment what may make the
(00:58:19)
disorder break through into full
(00:58:21)
disorder is that something happened to
(00:58:24)
that cerebellum
(00:58:27)
that's an interesting possibility
(00:58:29)
remains to be replicated but that's a
(00:58:31)
finding from research at UCLA so what's
(00:58:34)
going on the brain is not developing on
(00:58:35)
time we know that from the Montreal New
(00:58:38)
York
(00:58:39)
Washington multi-site study in which
(00:58:42)
223 ADHD and normal children were
(00:58:45)
scanned serially over a period of about
(00:58:47)
10 years this is the first developmental
(00:58:49)
neuroimaging study and what did it find
(00:58:53)
that the frontal lobe of the brain
(00:58:54)
primarily is about 2 to 3 years delayed
(00:58:56)
in its growth this is a study of growth
(00:58:59)
not function just brain size and what
(00:59:03)
you're looking at is a top- down view of
(00:59:04)
the brain and these are the frontal
(00:59:07)
loes so there's about a 2 to threee
(00:59:10)
delay in your brain development and you
(00:59:11)
can see it in the right and in the left
(00:59:14)
hemisphere here as well so this was a
(00:59:16)
groundbreaking study demonstrating that
(00:59:19)
the brain is late in these crucial
(00:59:22)
executive areas to develop now the
(00:59:25)
better parent is going to be asking me
(00:59:26)
about this this is not the frontal lobe
(00:59:30)
what the heck is that right that's back
(00:59:33)
where your visual cortex is why would
(00:59:35)
that be involved in
(00:59:37)
ADHD the second executive function is
(00:59:39)
visual
(00:59:41)
imagery and that's involved in visual
(00:59:44)
imagery this part of the brain developed
(00:59:46)
too early this is the motor strip and it
(00:59:49)
developed about two to three years
(00:59:51)
earlier and it's where the hyperactivity
(00:59:53)
is coming from so you've got a motor
(00:59:56)
strip that's generating behavior and a
(00:59:58)
frontal lobe that's not regulating it so
(01:00:01)
I would want parents to understand that
(01:00:02)
this is a brain-based
(01:00:04)
disorder and that it results in a
(01:00:07)
maturational lag and how rapidly these
(01:00:09)
parts of the brain are developing I want
(01:00:11)
the family coming to my clinic to
(01:00:13)
understand that most of these
(01:00:13)
differences originate in genetics but
(01:00:16)
that about a third of the male patients
(01:00:18)
that we see May well have acquired their
(01:00:20)
ADHD in girls it's far less than that in
(01:00:23)
fact it's fair to say that the vast
(01:00:24)
majority of girls have the genetic type
(01:00:27)
of the disorder but about a third of the
(01:00:29)
boys may have acquired their disorder we
(01:00:31)
know that ADHD runs in families and half
(01:00:33)
for 40 years here are the risk if you
(01:00:34)
have an ADHD child 25 to 35% of their
(01:00:38)
brothers and sisters will have the same
(01:00:39)
disorder if you're an identical twin
(01:00:41)
that risk is 78 to
(01:00:43)
92% notice that the closer people are
(01:00:45)
genetically related the higher the risk
(01:00:47)
if one has the disorder that the other's
(01:00:49)
going to have the disorder now if we
(01:00:51)
bring in their mothers and evaluate them
(01:00:52)
upwards of one5 of their mothers are
(01:00:54)
still adults with ADHD
(01:00:56)
and nearly a third of their fathers are
(01:00:59)
currently ADHD and if you add those two
(01:01:01)
together it means that there's a 50%
(01:01:03)
chance that one of the parents sitting
(01:01:04)
across your desk has the same disorder
(01:01:07)
probably never diagnosed which is why we
(01:01:09)
now teach clinicians that you should be
(01:01:11)
screening every parent that brings a
(01:01:12)
child to your clinic oh and by the way
(01:01:14)
if you're an adult with ADHD 40 to 54%
(01:01:18)
of your children will have the same
(01:01:19)
disorder that is a profoundly genetic
(01:01:24)
disorder nearly half of the off spring
(01:01:26)
of adults with ADHD have ADHD as
(01:01:29)
well we know from twin studies that the
(01:01:32)
vast majority of ADHD is due to genetic
(01:01:35)
differences on average 80% of the
(01:01:38)
differences in people in this room in
(01:01:39)
their ADHD symptoms are due to
(01:01:41)
differences in their genes and in the
(01:01:43)
last few studies it was as high as human
(01:01:45)
height about
(01:01:48)
91% twin studies allow us to calculate
(01:01:50)
how much of a trade is due to the
(01:01:52)
rearing environment and it's zero all 40
(01:01:55)
twin St iies published in the last 20
(01:01:58)
years have shown that the rearing
(01:02:00)
environment has no influence on this
(01:02:04)
trait yet the public believes that ADHD
(01:02:07)
originates in bad
(01:02:09)
parenting the twin studies also tell us
(01:02:11)
that there's a small percentage of ADHD
(01:02:13)
that's arising from non- gentic causes
(01:02:16)
and those are those acquired injuries
(01:02:18)
that we talked about
(01:02:20)
earlier and just in case you were
(01:02:22)
wondering yes we are discovering genes
(01:02:24)
for ADHD we have had more success in
(01:02:27)
this area of Psychiatry than with any
(01:02:29)
other disorder that I know of we now
(01:02:32)
know from genome scans published us last
(01:02:34)
year where we've scanned all 35,000
(01:02:37)
active human genes for ADHD genes that
(01:02:40)
it's going to be about 20 to 25 sites
(01:02:43)
and out of those 20 to 25 sites we've
(01:02:45)
nailed down about five to seven of them
(01:02:48)
and here's a
(01:02:49)
few I want you to notice that there's a
(01:02:51)
D in front of the first four genes it
(01:02:54)
means that those genes regulate dopamine
(01:02:57)
in the brain so no surprise the genes
(01:03:00)
that regulate dopamine are ADHD rist gen
(01:03:03)
and no surprise that drugs that improve
(01:03:05)
dopamine in the brain work for ADHD
(01:03:08)
because those drugs are altering the
(01:03:10)
effects of these genes in the brain
(01:03:13)
which means that psychopharmacology is a
(01:03:15)
form of genetic treatment isn't that
(01:03:17)
fascinating it's not a Band-Aid it's not
(01:03:20)
a cover up it's not missing the point
(01:03:23)
it's actually helping to manage the
(01:03:25)
underlying genetic problems if you will
(01:03:28)
the genetic differences in the
(01:03:31)
brain now let me take one of these genes
(01:03:33)
and explain it to you because it's kind
(01:03:34)
of cool I won't go through all the genes
(01:03:36)
but bear with me this is a nerve cell
(01:03:38)
that I pulled out of your frontal lobe
(01:03:40)
ouch I'll bet that
(01:03:42)
hurt and if you look at this nerve cell
(01:03:45)
when this little baby gets stimulated an
(01:03:46)
electrical impulse is going to proceed
(01:03:48)
down this nerve cell and as that impulse
(01:03:51)
reaches the end of the nerve cell these
(01:03:53)
little packets of chemicals dopamine are
(01:03:56)
going to move toward the outside
(01:03:57)
membrane and burst and as they burst
(01:04:01)
they're going to spray dopamine out into
(01:04:03)
that little Gap called a synapse and if
(01:04:06)
there's enough dopamine out there it's
(01:04:07)
going to cross over and bind to this
(01:04:09)
membrane and it's going to fire the next
(01:04:11)
nerve cell in line and that's how your
(01:04:13)
brain works neuroelectrical impulses but
(01:04:17)
the point here is that there's dopamine
(01:04:19)
being squirted outside the nerve cell
(01:04:21)
now do you see this little baby right
(01:04:23)
here that's a vacuum cleaner and there
(01:04:26)
there are many of them on the outside of
(01:04:27)
this nerve cell because the job of that
(01:04:29)
little pump excuse
(01:04:31)
me the job of that little pump is to
(01:04:34)
vacuum up all the dopamine once it's
(01:04:36)
done its job and it's known as The
(01:04:38)
reuptake
(01:04:39)
Transporter and one of the genes I
(01:04:41)
showed you called dat1 builds and
(01:04:44)
operates that
(01:04:45)
pump if you have a longer version of
(01:04:48)
that Gene you have too many pumps on
(01:04:50)
your nerve cell which means when this
(01:04:52)
nerve cell fires the dopamine gets
(01:04:55)
vacuum right back up again again and it
(01:04:57)
can't do its job and it leaves you in a
(01:04:59)
state of too little
(01:05:01)
dopamine now here's the really cool part
(01:05:04)
people with ADHD have about 30 to 80%
(01:05:07)
more of these vacuum cleaners on their
(01:05:08)
nerve cells in the basal ganglia and the
(01:05:12)
other cool part is you want to know what
(01:05:14)
Ridin does to the brain or conserta when
(01:05:16)
you take it it goes right there and it
(01:05:19)
plugs up the vacuum cleaner like a sock
(01:05:22)
at the end of a vacuum hose
(01:05:24)
methylphenidate stops the transporter
(01:05:27)
from working what does that do leaves
(01:05:29)
more dopamine outside your nerve cell
(01:05:32)
methylphenidate is a dopamine reuptake
(01:05:35)
inhibitor by the way sta does the same
(01:05:38)
thing but it does it for norepinephrine
(01:05:40)
little bit for dopamine but nevertheless
(01:05:42)
we can now link a gene to a problem in
(01:05:45)
the brain and we can link that problem
(01:05:47)
to a drug you shouldn't be surprised to
(01:05:49)
find that that Gene is a predictor of
(01:05:51)
who is going to respond to
(01:05:54)
methylen at least in the last three
(01:05:56)
studies that have looked at it which
(01:05:57)
means that sometime in the future when
(01:06:00)
you go into an office we may take some
(01:06:01)
of your saliva genotype you and decide
(01:06:04)
which drug to give you because it's
(01:06:06)
looking like genes will predict your
(01:06:08)
drug response so I would want families
(01:06:10)
to know that because that's probably 5
(01:06:13)
years out maybe maybe more maybe less
(01:06:17)
but it's not just genes genes can
(01:06:19)
interact with your environment and
(01:06:20)
that's the purpose of this slide is to
(01:06:21)
show you very quickly a paper published
(01:06:23)
a year ago by Richard Todd who died died
(01:06:26)
suddenly shortly after publishing this
(01:06:28)
paper one of our great psychiatric
(01:06:29)
geneticists in St
(01:06:31)
Louis what you are seeing here is
(01:06:34)
children who were genotyped to see
(01:06:36)
whether or not they had that dat Gene I
(01:06:38)
just mentioned and another wrist Gene a
(01:06:40)
plus means you got the gene a minus
(01:06:42)
means you didn't now the Top Line you
(01:06:44)
see those y's and n's that's whether or
(01:06:46)
not your mother smoked during her
(01:06:48)
pregnancy with you I want you to look
(01:06:50)
all the way over here right side if you
(01:06:53)
got both of these genes and your mother
(01:06:55)
Smoked Cigarettes you are eight times
(01:06:56)
more likely to get this disorder than
(01:06:58)
anybody who had either one of those
(01:07:00)
causes that is a gene by toxin
(01:07:03)
interaction and we have now found the
(01:07:05)
same thing for
(01:07:07)
alcohol so some ADHD is the result of
(01:07:10)
both a genetic predisposition of risk
(01:07:12)
and the fact that the mother may have
(01:07:14)
consumed a
(01:07:15)
toxin during the pregnancy of that child
(01:07:19)
we know that genetic research is the
(01:07:21)
fastest moving area of research right
(01:07:23)
now in ADHD research out of all areas of
(01:07:26)
of study this is the one that is moving
(01:07:27)
so quickly there are 100 articles a year
(01:07:29)
published on this subject alone right
(01:07:33)
what can we expect from this rapidly
(01:07:35)
advancing study we can expect to do
(01:07:37)
genetic testing to help with diagnosis
(01:07:39)
we can expect to start subtyping you on
(01:07:41)
the kind of ADHD you probably have this
(01:07:44)
is going to give us a better idea of
(01:07:45)
what you are at risk for because we are
(01:07:47)
already beginning to label and detect
(01:07:49)
that these genes carry risk for other
(01:07:51)
disorders not just ADHD for instance
(01:07:54)
that dat Gene that regulates transporter
(01:07:56)
is a predictor of nicotine
(01:07:59)
addiction we also know that these genes
(01:08:01)
are going to interact with each other
(01:08:02)
and with toxins in the environment so
(01:08:04)
that's going to help explain why some
(01:08:06)
people got ADHD and as you see here it
(01:08:08)
may help in predicting drug response and
(01:08:10)
notice we now have a paper just
(01:08:12)
published within the last year that
(01:08:14)
shows that whether or not your child
(01:08:16)
responds to behavior modification is
(01:08:18)
partly related to some of these genes
(01:08:21)
sensitivity to psychological treatment
(01:08:23)
may be in part genetically mediate ated
(01:08:27)
expect to see new drugs being developed
(01:08:29)
just for these genes and new
(01:08:31)
psychosocial treatments may be developed
(01:08:33)
for certain genetic subtypes how cool is
(01:08:36)
that I would want families therefore to
(01:08:39)
leave my office understanding that ADHD
(01:08:41)
does not arise out of the family or from
(01:08:44)
social causes and especially to
(01:08:47)
understand that these things that are
(01:08:48)
very popular in the media and among many
(01:08:51)
uninformed parents are not causes of
(01:08:54)
ADHD for the most part not the least of
(01:08:56)
which is
(01:08:58)
Television TV and video game playing are
(01:09:01)
not causing short attention spans if I
(01:09:03)
hear this again in the media I'm going
(01:09:04)
to throw
(01:09:06)
up this is now taken as gospel it is
(01:09:09)
mere folklore there is no evidence that
(01:09:11)
human attention spans have changed at
(01:09:13)
all what is changing is the amount of
(01:09:16)
media you can distract yourself with if
(01:09:18)
you so
(01:09:19)
choose but it doesn't mean that this is
(01:09:21)
causing a short attention span you've
(01:09:23)
just got more media to pay attention to
(01:09:25)
okay
(01:09:26)
and of course if you are easily
(01:09:28)
distracted and you don't like to read
(01:09:29)
for pleasure or sustain your attention
(01:09:31)
to things you got a lot of choices out
(01:09:33)
there so we do know that people with
(01:09:35)
ADHD watch television more play video
(01:09:38)
games more use the internet more talk on
(01:09:40)
their cell phones more text message and
(01:09:41)
Twitter more than other people do that
(01:09:44)
doesn't mean these things cause their
(01:09:46)
ADHD it's the other way around ADHD
(01:09:49)
leads you to select these as leisure
(01:09:52)
activities because they're so engaging
(01:09:55)
we know that food additives don't cause
(01:09:56)
this disorder but about one in 20 ADHD
(01:09:59)
children could be exacerbated by a
(01:10:01)
little bit of these things in their diet
(01:10:02)
but it's a minor trivial scientific
(01:10:05)
finding you don't need to go changing
(01:10:07)
your child's diet as a means of dealing
(01:10:09)
with ADHD and by the way that includes
(01:10:11)
supplements like Omega-3s which were
(01:10:13)
recently found to benefit less than 25%
(01:10:16)
of ADHD only thect inattentive type
(01:10:19)
appeared to benefit it was modest it was
(01:10:21)
trivial uh but it was kind of
(01:10:23)
interesting but ADHD combined type did
(01:10:26)
not appear to benefit much from fish oil
(01:10:30)
that's a nice randomized trial published
(01:10:31)
in Sweden just about 2 months ago and of
(01:10:34)
course we know that child rearing has
(01:10:37)
nothing to do with it so I would want
(01:10:38)
the family to understand here is a pie
(01:10:40)
chart of the causes of ADHD 65% roughly
(01:10:43)
genetic all the rest are biohazards that
(01:10:46)
can provide or produce brain injuries
(01:10:48)
and there is no social Factor on that
(01:10:51)
list
(01:10:59)
now viewing ADHD as this neurogenetic or
(01:11:01)
neurobiologic disorder of
(01:11:03)
self-regulation brings with it some very
(01:11:05)
important insights I would want you and
(01:11:08)
families who I counsel to understand not
(01:11:10)
the least of which is this
(01:11:14)
one this is ADHD rid
(01:11:18)
large it's always
(01:11:20)
now
(01:11:22)
ADHD is to summarize it in a single
(01:11:26)
phrase time
(01:11:29)
blindness people with ADHD cannot deal
(01:11:31)
with time and that includes looking back
(01:11:34)
to look ahead to get ready for what's
(01:11:36)
coming at you so the individual with
(01:11:38)
ADHD is kind of living in the now and
(01:11:40)
wherever the now goes they are being
(01:11:42)
pulled Along by the nose wherever it
(01:11:45)
goes I'll give you an example from our
(01:11:46)
adults Clinic it's rather funny but it
(01:11:49)
wasn't to his wife this couple came into
(01:11:52)
our office in Massachusetts once and she
(01:11:53)
said let me tell you what it's like
(01:11:54)
living with this guy
(01:11:56)
because it's like having a fourth child
(01:11:58)
actually this is what happened last
(01:12:00)
weekend she says if you can't do
(01:12:02)
something about this I'm leaving him
(01:12:04)
here's what happened he went out to mow
(01:12:06)
the yard he wheeled the lawnmower out of
(01:12:08)
the garage and the tank was empty so he
(01:12:10)
reached for the fuel can it was empty
(01:12:12)
too so he threw it in the back of the
(01:12:14)
Ford Explorer and headed down to the
(01:12:15)
little Quicky Mart and while I was
(01:12:18)
filling up the gas can his buddy pulls
(01:12:20)
in in his Ford explore and says you know
(01:12:22)
it's opening day on the troutstream what
(01:12:25)
do you say we go fish a little bit and
(01:12:27)
so the guy hops in his buddy's Explorer
(01:12:29)
and they go fly
(01:12:31)
fishing and they are out for 6 hours and
(01:12:33)
then they get thirsty and decide to stop
(01:12:36)
off at a pub for a beer so now they're
(01:12:37)
at the little Local Tavern this is a
(01:12:39)
True Story by the way because within an
(01:12:41)
hour the state police had found his car
(01:12:43)
still running in an open gas can at the
(01:12:45)
Quicky
(01:12:47)
M and he finally wandered home at 4:00
(01:12:50)
in the
(01:12:51)
afternoon do you see what happens
(01:12:53)
doesn't matter what your plans were what
(01:12:55)
your goals were the now is more
(01:12:57)
compelling than the information you're
(01:12:59)
holding in mind and you will get pulled
(01:13:02)
Along by the now you are time blind
(01:13:06)
because if we had to summarize in a
(01:13:09)
single sentence what is the purpose of
(01:13:12)
the frontal lobe to humans it is to
(01:13:14)
organize your behavior across time in
(01:13:17)
anticipation of what is coming at you
(01:13:20)
the future so ADHD creates a blindness
(01:13:24)
to time or technically to be more
(01:13:26)
accurate a nearsightedness to the Future
(01:13:30)
can you say that again
(01:13:33)
yes I can only be eloquent once
(01:13:37)
no this is extemporaneous I'm not okay
(01:13:42)
ADHD right is at its heart a blindness
(01:13:45)
to time or technically to be exact it is
(01:13:48)
a nearsightedness to the Future just as
(01:13:52)
people who are nearsighted can only read
(01:13:53)
things close at hand people with ADHD
(01:13:56)
can only deal with things near in
(01:13:59)
time the further out the event lies the
(01:14:03)
less they are capable of dealing with it
(01:14:06)
and this is why everything is left on
(01:14:07)
the last minute because they only deal
(01:14:10)
with last minutes that's all they
(01:14:12)
perceive that's all they deal with
(01:14:13)
that's all they organize too and so
(01:14:15)
their life is a series of one crisis
(01:14:17)
after another all of which were
(01:14:18)
avoidable because people prepared and
(01:14:21)
they didn't they weren't ready on time
(01:14:24)
in time over time with what they needed
(01:14:26)
at that
(01:14:28)
time note the word time right so ADHD is
(01:14:32)
destroying the timing and timeliness of
(01:14:34)
human behavior that is a very important
(01:14:36)
thing for parents to understand because
(01:14:38)
while a three-year-old does not have to
(01:14:40)
have a sense of time a 30-year-old does
(01:14:43)
and one of the most devastating deficits
(01:14:45)
in adult life that ADHD produces is a
(01:14:48)
disruption in the fabric of time they
(01:14:52)
can't cope with it as well as others now
(01:14:55)
this ability to organize across time
(01:14:57)
comes with the capacity to build
(01:15:00)
pyramids of behavior from Little
(01:15:02)
behaviors to the bigger behaviors above
(01:15:05)
them to the bigger goals above them all
(01:15:08)
human behavior can be organized into a
(01:15:10)
hierarchy think about planning a wedding
(01:15:12)
can you imagine the hierarchy you would
(01:15:14)
have to create the decision trees and
(01:15:17)
when they would have to be done and when
(01:15:18)
you would have to book the church and
(01:15:20)
get the minister and get the flowers and
(01:15:22)
book the reception hall and all of those
(01:15:24)
come with little sub routines like
(01:15:26)
picking up a telephone and calling your
(01:15:28)
minister right it's the frontal lobe
(01:15:31)
that allows you to organize all of those
(01:15:33)
toward the single overarching purpose
(01:15:37)
the
(01:15:38)
wedding and that's what ADHD destroys
(01:15:41)
people with ADHD cannot hierarchically
(01:15:44)
organize behavior and so they are
(01:15:46)
accustomed to dealing with behaviors in
(01:15:49)
little fits and starts but they can't
(01:15:51)
glue those together as well as others to
(01:15:54)
create the bigger goal to the bigger
(01:15:56)
goal all the way up and that's why you
(01:15:59)
see a short attention span it's not
(01:16:01)
really a short attention span it's the
(01:16:02)
inability to organize Behavior across
(01:16:05)
time into a
(01:16:07)
hierarchy the ability to look ahead is
(01:16:09)
called
(01:16:10)
intention so ADHD is actually ID it's
(01:16:14)
intention deficit disorder because it
(01:16:16)
doesn't matter what your intentions are
(01:16:18)
you're not going to do
(01:16:22)
them
(01:16:24)
so oh you can head out the door for
(01:16:26)
school in the morning and promise your
(01:16:28)
mother that you will not be put in time
(01:16:29)
out again you really will get it right
(01:16:32)
today you will behave yourself you will
(01:16:34)
not fight with the other kids you will
(01:16:36)
finish your work and you mean it
(01:16:39)
sincerely but within an hour your
(01:16:41)
mother's getting the usual call that
(01:16:42)
you're in timeout and that you're
(01:16:44)
disruptive and they need to come and get
(01:16:46)
you right notice what happens your
(01:16:48)
intentions are not the problem and it's
(01:16:50)
not insincerity it's the inability to
(01:16:53)
organize around those intentions so add
(01:16:56)
is really ID now I want you to
(01:16:58)
understand something your brain can be
(01:17:00)
split into two pieces the back part is
(01:17:03)
where you acquire knowledge the front
(01:17:05)
part is where you use it the back part
(01:17:08)
is knowledge the front part is
(01:17:10)
performance ADHD like a meat cleaver
(01:17:13)
just split your brain in half so it
(01:17:16)
doesn't matter what you know you won't
(01:17:17)
use it you have what we call in
(01:17:20)
Psychology a performance disorder
(01:17:23)
performance disorders have nothing to do
(01:17:24)
with skill you have all the skills other
(01:17:26)
people your age possess but you can't
(01:17:29)
use them because you see it's the
(01:17:31)
executive system where the rubber meets
(01:17:32)
the road where what you know gets
(01:17:34)
applied in every day what you do and
(01:17:37)
ADHD is a disorder of doing what you
(01:17:40)
know it is not a disorder of knowing
(01:17:42)
what to do and that is a very important
(01:17:45)
thing I want families to understand as
(01:17:47)
well your child unless they were raised
(01:17:49)
in a zoo or in a very impoverished area
(01:17:53)
or were adopted out of some far-fetched
(01:17:54)
War War torn undeveloped
(01:17:57)
country has all the information and
(01:17:59)
knowledge that the other kids their age
(01:18:01)
have what they can't do is use
(01:18:04)
it it is the application of what you
(01:18:07)
know that this disorder robs you of so
(01:18:10)
you can be the smartest person on the
(01:18:12)
planet and you're still going to do some
(01:18:13)
pretty stupid
(01:18:14)
things because it's not what you know
(01:18:17)
it's doing
(01:18:18)
it so I would want parents to understand
(01:18:21)
that that is a very profound disturbance
(01:18:24)
in a person's Behavior
(01:18:26)
but it arises out of Neurology and
(01:18:27)
genetics and out of this is going to
(01:18:29)
come a very important view of what to do
(01:18:32)
about this
(01:18:33)
disorder the first thing this is going
(01:18:35)
to
(01:18:37)
mean is to stop teaching so many damn
(01:18:41)
skills because you're approaching this
(01:18:43)
child as if he's stupid right oh he
(01:18:46)
doesn't have any friends I guess he
(01:18:48)
doesn't know social skills so we'll take
(01:18:50)
him down to the local clinic and we'll
(01:18:51)
enroll him in a 12we social skills Camp
(01:18:54)
about which we'll probably pay $50 to
(01:18:55)
$100 a session or we'll send them to the
(01:18:58)
Upper Peninsula of Michigan where
(01:18:59)
there's a nice summer social skills camp
(01:19:01)
that was advertised in Chad's attention
(01:19:03)
magazine there is it's probably a very
(01:19:05)
nice Camp I don't mean to belittle it
(01:19:07)
I'm just telling you it will do no good
(01:19:11)
right well now let's understand
(01:19:14)
something I might want to send a child
(01:19:15)
to Camp just to have fun right it's part
(01:19:17)
of the quality of life go have a nice
(01:19:19)
summer but if I'm sending you to Camp
(01:19:23)
with the belief that you're going to
(01:19:24)
come back a person with better social
(01:19:26)
skills you are sadly mistaken right so
(01:19:30)
we have got to stop putting all the eggs
(01:19:32)
in the skill training basket because
(01:19:35)
that's not where the problem is right we
(01:19:38)
have got to spend more time changing the
(01:19:41)
point of
(01:19:43)
performance the point of performance is
(01:19:45)
where you should be using what you know
(01:19:47)
and you're not and the only way to treat
(01:19:50)
a performance disorder is to change that
(01:19:52)
point this means that all treat
(01:19:55)
treatment if it is going to work at all
(01:19:58)
must be at the point of performance the
(01:20:00)
place in your life where you're not
(01:20:02)
using what you already know and if the
(01:20:04)
intervention isn't done there it's
(01:20:07)
useless that has been a major finding of
(01:20:09)
the last decade the only treatments that
(01:20:12)
work are treatments that modify those
(01:20:14)
natural points in the environment where
(01:20:17)
the problems are occurring and if those
(01:20:19)
aren't modified nothing done away from
(01:20:22)
that site will do anything
(01:20:25)
so you can do pullout Services you can
(01:20:27)
go to summer or to social skills camps
(01:20:30)
you can go to special ed you can come
(01:20:32)
and see me for once a week for
(01:20:34)
Psychotherapy and everything I just said
(01:20:36)
will have no generalization or
(01:20:37)
maintenance won't go anywhere won't even
(01:20:39)
leave this room Howard abov tells a
(01:20:41)
beautiful story of the social skills
(01:20:42)
group he ran and on the day they covered
(01:20:45)
anger management and sharing he opened
(01:20:47)
the door to the room and there was a
(01:20:48)
fist fight in the hall by the
(01:20:50)
elevator over who was going to push the
(01:20:53)
button so much for your anger management
(01:20:58)
right you see what happens you were
(01:21:00)
focusing on knowledge oh let me teach
(01:21:02)
you how to share and cooperate and you
(01:21:05)
missed the point this is not information
(01:21:08)
deficit
(01:21:09)
disorder right this is performance
(01:21:11)
Deficit
(01:21:13)
Disorder so you got to change those
(01:21:15)
points of performance if he has no
(01:21:16)
friends on the playground you're going
(01:21:17)
to have to do something at that school
(01:21:19)
if you got trouble with homework it's
(01:21:20)
the kitchen table honey it's not my
(01:21:23)
office we need to rearrange where the
(01:21:25)
homework is being done to help them show
(01:21:27)
what they know as I've already said this
(01:21:29)
point of view also then makes us look
(01:21:31)
very differently at psychopharmacology
(01:21:32)
as a form of neurogenetic treatment now
(01:21:35)
everything I have just said could be
(01:21:36)
used by any parent to come up to me and
(01:21:39)
say my child got thrown out of school
(01:21:41)
yesterday for some misbehavior would you
(01:21:43)
please go to school and get him
(01:21:45)
reinstated he should not be held
(01:21:46)
accountable for these consequences right
(01:21:49)
because after all didn't you just say
(01:21:50)
it's a neurogenetic disorder so let me
(01:21:52)
help you understand something about what
(01:21:54)
I've just said
(01:21:56)
ADHD does not cause a problem with
(01:21:58)
consequences the problem is with time it
(01:22:01)
was the delay to the consequence that
(01:22:04)
disabled you which means that I'm going
(01:22:08)
to do the opposite of what this mother
(01:22:09)
is asking increase accountability not
(01:22:13)
decrease it increase the frequency
(01:22:16)
immediacy the salience and the timing of
(01:22:19)
consequences people with ADHD need more
(01:22:22)
accountability not no accountability in
(01:22:25)
fact this view of ADH as an executive
(01:22:27)
disorder would tell you that if you
(01:22:28)
argue for no accountability you will
(01:22:30)
make this disorder worse not better
(01:22:33)
because the problem is the delay and all
(01:22:37)
natural consequences of any importance
(01:22:40)
are
(01:22:43)
delayed what does that mean we are going
(01:22:45)
to have to use behavioral treatments the
(01:22:47)
bod programs The Tokens The Charts the
(01:22:49)
cards the Smur stickers whatever what is
(01:22:52)
their purpose their purpose is not to
(01:22:54)
teach that is a misnomer if you will
(01:22:57)
their purpose is to sprinkle artificial
(01:23:00)
consequences into these delays in the
(01:23:03)
natural
(01:23:04)
environment in order to increase your
(01:23:07)
accountability so they're not teaching
(01:23:09)
anything they are making up for the
(01:23:12)
accountability deficit
(01:23:14)
disorder bod does not teach anything to
(01:23:17)
ADHD children really what it does is
(01:23:20)
improve the motivation to show what You
(01:23:23)
Know by making you more accountable more
(01:23:26)
often around you you have less ADHD by
(01:23:30)
excusing you from the consequences
(01:23:32)
you'll be more ADHD so I want you to
(01:23:35)
understand something there are two
(01:23:36)
reasons why we would tell you as a
(01:23:38)
family to do behavior modification one
(01:23:41)
is instructional this is why we teach
(01:23:43)
families of autistic and mentally
(01:23:45)
children behavior modification
(01:23:47)
to teach their children things they
(01:23:49)
don't know but the second purpose you
(01:23:52)
would do bod for has nothing to do with
(01:23:54)
instruction
(01:23:55)
it's motivational to make up for the
(01:23:58)
motivation deficit disorder that this
(01:24:00)
disorder
(01:24:01)
produces and so if you do be mod for its
(01:24:04)
motivational value you can't stop it
(01:24:07)
because if you pull it you've pulled the
(01:24:08)
motivation if you do be mod for its
(01:24:10)
instructional purpose you can pull it
(01:24:13)
because once they've acquired the skill
(01:24:15)
they'll use the skill and you don't have
(01:24:16)
to worry about it anymore now do you see
(01:24:18)
it a contrast here most parents and
(01:24:21)
nearly all teachers I deal with believe
(01:24:24)
that bod is for instructional value
(01:24:27)
that's why we do it for ADHD which is
(01:24:29)
why whenever you go into a school and
(01:24:30)
you try to teach a teacher to set up a
(01:24:31)
token system the first question out of
(01:24:34)
his mouth is how long do I have to do
(01:24:36)
this when will he internalize the
(01:24:39)
program and my answer is
(01:24:42)
never as long as he's in your class you
(01:24:45)
will have to arrange artificial
(01:24:47)
consequences to replace the delayed ones
(01:24:50)
and if you don't do that he will not
(01:24:51)
work for you so I want you to think
(01:24:53)
about token systems and star charts and
(01:24:56)
all behavior modification as being
(01:24:58)
equivalent to a ramp that comes into
(01:25:00)
this building that ramp is there to make
(01:25:03)
people who are physically disabled less
(01:25:06)
motorically impaired they can get into
(01:25:08)
the building in their wheelchairs or
(01:25:10)
whatever other devices they're using but
(01:25:13)
would you ever say to such a person
(01:25:15)
after 30 days of entering this building
(01:25:17)
successfully using the
(01:25:19)
ramp you know
(01:25:22)
where you know the punchline right can I
(01:25:25)
take the ramp away have they
(01:25:26)
internalized the ramp well of course not
(01:25:29)
the ramp was never for teaching right
(01:25:31)
the ramp is a
(01:25:35)
prosthesis a prosthesis is an artificial
(01:25:37)
means of reducing the disabling
(01:25:40)
consequences of your disorder it is not
(01:25:43)
to train you up into anything no amount
(01:25:45)
of using a ramp is going to take the
(01:25:47)
ramp away and no amount of bod is going
(01:25:50)
to take the bod
(01:25:52)
away these individuals will always need
(01:25:55)
more frequent consequences around them
(01:25:57)
than will other people in order to
(01:25:59)
perform at the same level it's just a
(01:26:01)
general Cory of
(01:26:04)
ADHD so what else have we learned about
(01:26:06)
ADHD well if all treatment is at that
(01:26:08)
point of performance and if at that
(01:26:10)
point of performance I'm trying to
(01:26:11)
arrange a prosthesis a prosthetic
(01:26:13)
environment to reduce the impairment
(01:26:16)
from the disability right then it means
(01:26:19)
that the caregivers are the most
(01:26:20)
important people in the treatment plan
(01:26:23)
the parents and the teachers it is their
(01:26:25)
compassion for disabled people and their
(01:26:28)
willingness to make these prosthetic
(01:26:30)
accommodations that is the heart of any
(01:26:33)
successful intervention and absent that
(01:26:36)
compassion no amount of quality in a
(01:26:39)
good professional or therapist is going
(01:26:40)
to change that you have to make those
(01:26:43)
people stakeholders you've got to get
(01:26:45)
them invested and if they're not you're
(01:26:46)
in trouble it doesn't matter how good a
(01:26:48)
clinician you are so it's best to look
(01:26:51)
at ADHD I would be telling these
(01:26:52)
families in my office like we look at at
(01:26:55)
diabetes largely a chronic
(01:26:58)
disorder and our goal is to manage it to
(01:27:01)
create a reduction in the
(01:27:03)
symptoms the purpose of which is the
(01:27:06)
avoidance of secondary harm we do not
(01:27:09)
treat diabetes to get rid of it we treat
(01:27:11)
it to prevent what happens to you if you
(01:27:13)
don't manage your diabetes because you
(01:27:15)
will go blind and your heart muscle will
(01:27:17)
atrophy and you are at risk for sudden
(01:27:19)
death and you will get gang green and
(01:27:22)
you may have your toes or fingers or
(01:27:23)
other appendages of eventually amputated
(01:27:26)
if we do not manage your insulin levels
(01:27:29)
that is what we try to prevent but no
(01:27:31)
amount of treating diabetes is ever
(01:27:33)
designed to get rid of the diabetes and
(01:27:35)
I think ADHD is a very good analogy I
(01:27:38)
think we manage ADHD to prevent the
(01:27:40)
secondary harms which I'm about to show
(01:27:41)
you we don't manage ADHD to get rid of
(01:27:44)
it we manage it so that you don't
(01:27:46)
experience those more heinous
(01:27:49)
consequences
(01:27:58)
so by changing the environment you're
(01:27:59)
going to be able to help compensate for
(01:28:01)
the impaired executive abilities now the
(01:28:04)
ADHD view of ADHD the attention view
(01:28:07)
does not tell you what to do does not
(01:28:10)
not one wit does it guide me if you tell
(01:28:13)
me somebody is inattentive I don't know
(01:28:15)
what to do for them what more coffee as
(01:28:16)
I
(01:28:17)
said but if you tell me somebody has an
(01:28:20)
executive disorder I will give you five
(01:28:22)
things to do immediately at any point in
(01:28:27)
performance goodness it's 3:30 can I
(01:28:30)
give you a break right after this one
(01:28:32)
okay number
(01:28:34)
one your child cannot stop and hold
(01:28:38)
things in
(01:28:40)
mind so don't make them you need to use
(01:28:45)
external physical forms of information
(01:28:48)
which means sticky notes signs symbols
(01:28:51)
charts cues reminders the issue here is
(01:28:55)
not the what it's the why you must find
(01:28:59)
a substitute for working memory and that
(01:29:02)
means something external the information
(01:29:05)
whatever it is that is key for you to
(01:29:07)
remember right here right now needs to
(01:29:10)
be outside of your brain in the visual
(01:29:15)
field you have got to externalize as the
(01:29:19)
phrase for that the information that
(01:29:21)
other people are holding in mind it's
(01:29:24)
what we are doing after age 55 and women
(01:29:27)
in Perry menopause we are using a lot of
(01:29:29)
sticky notes let me tell you because I'm
(01:29:32)
59 years old and I already have a little
(01:29:35)
ADHD working memory disorder as do most
(01:29:38)
women by the way it hits women harder
(01:29:39)
than men but it hits us both
(01:29:42)
nevertheless we're all running around
(01:29:44)
with
(01:29:45)
lists what was I doing my wife even has
(01:29:48)
a digital memory recorder in her car so
(01:29:51)
that when she's out and she has to
(01:29:52)
remember something she dictates it in
(01:29:54)
there so so she can listen back and
(01:29:55)
remember what the heck she was supposed
(01:29:57)
to buy at the shopping
(01:29:59)
center you see what we're all doing
(01:30:02)
making up for a working memory deficit
(01:30:04)
you need to do the same thing with
(01:30:06)
ADHD if you're an adult with ADHD you
(01:30:09)
should not be going anywhere without a
(01:30:10)
paper journal in your pocket with a pen
(01:30:13)
because anything you agree to do or
(01:30:15)
anything others ask you to do is to be
(01:30:17)
immediately written in that journal and
(01:30:19)
that journal is welded to your body that
(01:30:23)
is your working memory use it and by the
(01:30:25)
way we find journals are better than
(01:30:28)
digital devices because they lose the
(01:30:30)
devices and they don't remember to turn
(01:30:31)
them on and they don't remember to
(01:30:33)
dictate into them so as good as those
(01:30:36)
things may sound and as high-tech as
(01:30:38)
they are the good old paper and pencil
(01:30:40)
notebook seems to do the job okay and if
(01:30:43)
I were you I would even have it on a
(01:30:45)
chain like a motorcycle gang member has
(01:30:47)
his wallet it is there from sun up to
(01:30:50)
sun down man when you put your pants on
(01:30:52)
that is in it all the time
(01:30:54)
right and now you have a working
(01:30:58)
memory you have no internal clock so if
(01:31:02)
anything involves time there must be a
(01:31:04)
timer there must be something physical
(01:31:06)
outside of you that signals the passage
(01:31:08)
of time for young children cooking
(01:31:10)
timers are great but there are various
(01:31:12)
other devices including watches that
(01:31:13)
beep every 5 minutes and vibrators that
(01:31:15)
you can buy at the add warehouse.com
(01:31:17)
that have digital timers built in and
(01:31:19)
you can set them to just vibrate in your
(01:31:21)
pocket every so often I don't care what
(01:31:23)
the stimulus is this is the why people
(01:31:26)
not the what right the why is you have
(01:31:30)
no sense of time so if I give you
(01:31:32)
something that involves time I have got
(01:31:34)
to give you a timer and if this extends
(01:31:36)
more than just a few minutes to a half
(01:31:38)
hour you are going to need a day planner
(01:31:40)
a Palm Pilot or some other means of
(01:31:42)
keeping track of time a week at a glance
(01:31:44)
calendar is not a bad thing either but
(01:31:47)
you are going to become timer and
(01:31:48)
calendar dependent
(01:31:50)
addicted so that you can organize your
(01:31:53)
life as well as other people who don't
(01:31:54)
need to rely on those things so much you
(01:31:57)
cannot see the future coming at you so
(01:31:59)
if there is something you've agreed to
(01:32:00)
do over time if this child has a book
(01:32:02)
report or a science project you are
(01:32:04)
going to break that into baby steps and
(01:32:06)
do a piece a day you are not going to
(01:32:08)
point at the future and keep harping
(01:32:09)
about summer reading have you done your
(01:32:11)
summer reading we've got that book
(01:32:14)
report that's due next week have you
(01:32:15)
done that right no we are going to take
(01:32:17)
the book report and you are going to
(01:32:19)
read three pages today you are going to
(01:32:20)
write four sentences today and I will
(01:32:22)
give you 15 tokens right now and that's
(01:32:24)
how we're going to get this done we are
(01:32:26)
going to break the future into pieces
(01:32:28)
and do a piece a day and stop pointing
(01:32:31)
at the future because you can't organize
(01:32:33)
to the Future that is your disability
(01:32:35)
that's like going on to an inpatient
(01:32:36)
unit at the psychiatric hospital and
(01:32:38)
saying God these people hallucinate
(01:32:40)
around here what's going on it's an
(01:32:42)
impatient unit they're schizophrenics
(01:32:44)
what did you think right you should not
(01:32:46)
be shocked that you have to break things
(01:32:48)
down for people who have a time
(01:32:49)
management disorder and so you should do
(01:32:52)
it for people with ADHD as well break
(01:32:54)
the future into pieces by the way what
(01:32:56)
does e mean on this it means that the
(01:32:59)
future comes at you in three pieces the
(01:33:02)
events that are coming toward you the
(01:33:04)
responses you prepare and the
(01:33:06)
consequences the outcomes of what you're
(01:33:08)
doing e o so here's the lesson I would
(01:33:12)
want this family to understand if those
(01:33:14)
e and rs and O's are kept close together
(01:33:17)
you don't need a frontal lobe and ADHD
(01:33:19)
people can do them that's a video
(01:33:21)
game but the minute you stretch these
(01:33:24)
things apart with time like a book
(01:33:27)
report you've got to read this book your
(01:33:30)
reports do in 30 days it'll take a week
(01:33:32)
to grade all the papers I just put a
(01:33:34)
month between the E and the r and a week
(01:33:36)
between the r and the O and if you have
(01:33:38)
ADHD you're disabled big
(01:33:41)
time so the solution is to get the es RS
(01:33:43)
and O's back together and that means
(01:33:45)
baby steps little e r o Bridges across
(01:33:48)
time and that's how you would do a
(01:33:50)
future assignment now how are we going
(01:33:52)
to deal with the fourth executive
(01:33:55)
function deficit the emotional
(01:33:57)
motivational one it means all motivation
(01:34:01)
is external we already talked about this
(01:34:04)
which means I am going to have to have
(01:34:06)
something in it for you if you are going
(01:34:08)
to persist so stop whining stop
(01:34:12)
complaining why you have to offer
(01:34:13)
something for this child to work the
(01:34:17)
reason you don't offer it to other
(01:34:18)
children is they have internal
(01:34:20)
motivation ADHD children do not so don't
(01:34:23)
worry that by paying them tokens for
(01:34:25)
doing their reading or their assignment
(01:34:27)
you're somehow going to pervert a sense
(01:34:30)
of doing things for their own reward or
(01:34:34)
value being a good citizen for the sake
(01:34:37)
of being a good citizen that is not
(01:34:38)
going to work for ADHD the ADHD child is
(01:34:41)
Donald Trump incarnate and there better
(01:34:43)
be a
(01:34:45)
deal and if there is no deal it ain't
(01:34:48)
getting done so to borrow a phrase from
(01:34:51)
Steven cvy please think win win
(01:34:55)
a win for them not just a win for you
(01:34:58)
and that means you are going to have to
(01:34:59)
drop in the points The Tokens The
(01:35:00)
privileges the sex of drugs and money in
(01:35:02)
the
(01:35:06)
car my medication's wearing off I
(01:35:10)
think the last executive function which
(01:35:13)
is mental Play It's the ability to
(01:35:15)
manipulate the contents of your mind in
(01:35:18)
creative ways to invent multiple
(01:35:21)
possibilities very hard for these people
(01:35:22)
this is why they can't do mental arith
(01:35:24)
as well as others it's why they can't do
(01:35:26)
digit span backward as well as others
(01:35:27)
it's why they have trouble playing the
(01:35:28)
little musical game Simon working memory
(01:35:32)
but if you can't hold things in working
(01:35:33)
memory then you can't manipulate your
(01:35:35)
working memory and that's where the
(01:35:37)
source of planning and problem solving
(01:35:38)
are coming from so what do we do well
(01:35:40)
we're going to take the same word we did
(01:35:41)
before externalize we're going to make
(01:35:43)
problem solving
(01:35:45)
manual physical you get to do it with
(01:35:48)
your hands so let's take math problems
(01:35:50)
I'm going to give you a bunch of marbles
(01:35:53)
a number l line and a Backus or a
(01:35:57)
calculator but the first three would
(01:35:58)
suffice right you're going to do math
(01:36:00)
with your hands the way it originally
(01:36:02)
was done I'm not going to ask you to do
(01:36:04)
arithmetic in your head you're going to
(01:36:06)
find that to be difficult you need a
(01:36:07)
crutch you need an
(01:36:09)
external prosthesis to help you with
(01:36:12)
your math now what if this is a verbal
(01:36:15)
problem or task like you've got to write
(01:36:17)
a story or an essay or something I'm
(01:36:19)
going to give you a stack of 3x5 file
(01:36:21)
cards and I want you to sit down and put
(01:36:23)
your mind on D
(01:36:24)
I want you to think of any idea you can
(01:36:26)
come up with that has to do with this
(01:36:28)
subject go I want a thought per card I
(01:36:30)
don't care what order I don't care what
(01:36:32)
sequence just let your mind run wild but
(01:36:35)
just give me a thought a card now I'm
(01:36:37)
going to take your cards and reorganize
(01:36:39)
them and now we've got them physical and
(01:36:41)
now we can create the story and the plot
(01:36:43)
line and if you do this on a laptop
(01:36:46)
computer in word you can even move it
(01:36:48)
around and spell check and cut and paste
(01:36:50)
and do all that need stuff because it's
(01:36:51)
now external your ideas have become
(01:36:53)
physical
(01:36:54)
and that's the secret here make the
(01:36:56)
mental information physical in some way
(01:37:00)
and then they might be able to do it
(01:37:03)
this may explain why more people with
(01:37:04)
ADHD wind up in the trades than in any
(01:37:06)
other
(01:37:08)
professions I used to think it was
(01:37:09)
because the trades don't require as much
(01:37:11)
Advanced education I now think it's
(01:37:13)
probably also the fact that it's manual
(01:37:17)
whether you're a carpenter a plumber a
(01:37:18)
landscaper a brick layer a tuner
(01:37:20)
electrician tuner of pianos I meant to
(01:37:22)
say or others
(01:37:24)
you are doing something manual and that
(01:37:27)
may matter we'll see lastly ADH rarely
(01:37:31)
occurs alone ADHD children are at risk
(01:37:34)
for all of these other disorders in fact
(01:37:37)
80% of ADHD children and adults will
(01:37:39)
have one of these other disorders and
(01:37:40)
50% will have at least two of these
(01:37:42)
other disorders so seeing ADHD by itself
(01:37:45)
is very rare seeing ADHD link up with a
(01:37:48)
few other disorders is not rare very
(01:37:50)
common and so I would want families to
(01:37:52)
understand that we may have to treat
(01:37:54)
other disorders not just the ADHD the
(01:37:57)
ADHD may be one problem and it may be
(01:37:59)
the biggest most impairing problem but
(01:38:01)
it's not the only problem that we may
(01:38:03)
have to deal with and on that note we
(01:38:06)
are going to give you a 10minute break
(01:38:08)
you will be called back at 10 minutes to
(01:38:10)
four because I got 15 other ideas I want
(01:38:13)
to share with
(01:38:17)
you thank you my pleasure thanks so much
(01:38:28)
so let me show you what untreated ADHD
(01:38:31)
is likely to have associated with it
(01:38:33)
over time and this is from my own
(01:38:36)
longitudinal study and others first of
(01:38:38)
all school is the major area of
(01:38:40)
impairment but we all know that they're
(01:38:42)
more likely to be held back in school a
(01:38:44)
third of them quit high school without
(01:38:45)
finishing only 5 to 10% ever finish
(01:38:48)
college so under education is a classic
(01:38:51)
ADHD impairment but but that of course
(01:38:54)
is going to lead to problems in the
(01:38:56)
workplace and you can see the ones that
(01:38:58)
we've identified here and it's also
(01:39:00)
going to lead to problems in driving
(01:39:02)
because we know the single biggest cause
(01:39:04)
of auto accidents in the North American
(01:39:06)
population is in vehicle
(01:39:08)
distraction and this is a
(01:39:10)
distractability disorder so no surprise
(01:39:13)
they're going to have problems but they
(01:39:14)
have problems at all levels of driving
(01:39:16)
as you see here more speeding tickets
(01:39:18)
more car accidents multiple accidents
(01:39:21)
worse accidents and as a result they're
(01:39:23)
going to have their licenses suspended
(01:39:25)
three times more often than other people
(01:39:27)
so driving becomes a major problem in
(01:39:29)
fact as has been said there is no
(01:39:31)
disorder that interferes with driving to
(01:39:33)
the degree that ADHD does so this is a
(01:39:36)
major area of impairment which is why
(01:39:38)
your Canadian Pediatric Association has
(01:39:40)
now recommended that if pediatricians
(01:39:43)
see a teenager who's about to start
(01:39:44)
driving and they have ADHD that is at
(01:39:46)
least moderate in severity you need to
(01:39:49)
medicate them while they drive I would
(01:39:51)
say that that should be the case for
(01:39:53)
nearly all clinically referred people
(01:39:54)
with ADHD because if they're clinically
(01:39:57)
referred they probably at least have it
(01:39:58)
to a moderate to a severe degree why is
(01:40:01)
that because you can kill yourself and
(01:40:03)
you can kill other people as well with a
(01:40:06)
motor vehicle and we don't want to see
(01:40:07)
that
(01:40:08)
happening now in addition to those there
(01:40:10)
are some other areas of impairment not
(01:40:12)
the least of which is managing money as
(01:40:14)
they move away from home as they get
(01:40:16)
jobs as they get credit as they borrow
(01:40:18)
money as they take out car loans we
(01:40:20)
start to see them having troubles paying
(01:40:22)
their bills paying them on time so that
(01:40:24)
they get their utilities turned off
(01:40:25)
their cars repossessed their credit
(01:40:27)
rating is terrible because you've given
(01:40:29)
a very impulsive person
(01:40:34)
[Applause]
(01:40:38)
credit boy could we use that these days
(01:40:41)
huh everybody working for AIG would go
(01:40:44)
on
(01:40:46)
this but this is an area that very few
(01:40:49)
people took a look at but duh I mean it
(01:40:51)
makes perfect sense when you phrase it
(01:40:53)
has a disorder of self-control given a
(01:40:55)
credit card and now we can understand
(01:40:58)
what's going to happen with the uh the
(01:41:00)
credit problems so obviously they need
(01:41:02)
more accountability in their financial
(01:41:04)
management social problems are going to
(01:41:06)
continue into adulthood for many though
(01:41:08)
not for all of them they often as adults
(01:41:10)
describe themselves as having trouble
(01:41:11)
sustaining long-term relationships
(01:41:13)
particularly dating and marital
(01:41:15)
relationships uh or partnering with
(01:41:17)
people uh and we will see that they do
(01:41:20)
experience divorce at a higher rate than
(01:41:23)
other people do because of these
(01:41:24)
difficulties an area now that has been
(01:41:27)
studied more in detail um is the area of
(01:41:29)
sexuality we do not find more sexual
(01:41:32)
Disorder so pedophilia transvestism or
(01:41:35)
other difficulties are not more common
(01:41:37)
in this population what we do find as
(01:41:40)
you would guess knowing an impulsive
(01:41:42)
person is greater risky sexual activity
(01:41:46)
starting to have intercourse a year
(01:41:48)
earlier than other teenagers having more
(01:41:50)
partners because they don't stay in
(01:41:51)
dating relationships as long not using
(01:41:54)
contraception because they're so
(01:41:56)
impulsive all of which leads to a
(01:41:58)
10-fold increase in teenage pregnancy we
(01:42:00)
now know in fact there is no better
(01:42:02)
predictor of adolescent pregnancies than
(01:42:05)
ADHD in my study 32% of the boys had
(01:42:08)
fathered a child by 19 68% of the girls
(01:42:12)
had been pregnant at least once before
(01:42:14)
19 years of age so this is a disorder
(01:42:18)
that predisposes to becoming a parent
(01:42:21)
very young and by the way we saw the
(01:42:22)
same thing in the parents of these kids
(01:42:24)
as well and that's because their parents
(01:42:26)
have ADHD also ADHD in adults leads to
(01:42:29)
earlier Parenthood than the general
(01:42:32)
population would be experiencing and
(01:42:35)
then of course notice a four-fold
(01:42:36)
increase in sexually transmitted
(01:42:39)
disease so we have a group of
(01:42:42)
individuals if who if not treated are
(01:42:44)
going to be experiencing impairments in
(01:42:46)
every major life activity we have
(01:42:48)
studied there is no domain of Life free
(01:42:50)
of the influence of ADHD that we have
(01:42:52)
yet identified
(01:42:54)
which is why we argue now for longer
(01:42:56)
term treatment across the week across
(01:42:59)
the year and especially through
(01:43:01)
adolescence because most children if
(01:43:03)
they're on medication it's for three
(01:43:05)
years or less and if they're in
(01:43:07)
treatment programs it's only for a few
(01:43:09)
years or less and what we have found in
(01:43:11)
these studies is that childhood only
(01:43:12)
treatment was useless useless in terms
(01:43:15)
of changing the life course of these
(01:43:17)
individuals now to understand why these
(01:43:20)
disorders why these impairments that is
(01:43:21)
would continue into adulthood we need to
(01:43:24)
go back and understand that it's a
(01:43:26)
disorder of
(01:43:28)
self-regulation and it's a quantitative
(01:43:30)
deficit so that begs the question how
(01:43:32)
far behind is this child and so the rule
(01:43:36)
that I have taught for years in our
(01:43:38)
clinics to families and it remains a
(01:43:40)
very good rule of thumb is the average
(01:43:44)
ADHD child is 30% behind their age some
(01:43:47)
are even more but on average across all
(01:43:50)
ADHD children it looks to be about 30%
(01:43:52)
so here's what I want parents to do if
(01:43:54)
your child is 10 he has the self-control
(01:43:56)
of a
(01:43:57)
seven-year-old that is how long he can
(01:43:59)
persist that is how long he can remember
(01:44:01)
that is how long he can go without
(01:44:03)
supervision his ability to
(01:44:06)
self-organize is that of a
(01:44:07)
seven-year-old now what would you do for
(01:44:09)
a seven-year-old how would we arrange
(01:44:12)
homework what else would we be doing
(01:44:14)
around chores around social functioning
(01:44:16)
around independence from parents you
(01:44:19)
wouldn't be doing as much as you would
(01:44:20)
with a 10-year-old you would not allow
(01:44:22)
as much responsibility as much Freedom
(01:44:24)
as much
(01:44:25)
Independence so I want parents to be
(01:44:29)
lowering their expectations to the
(01:44:31)
child's executive
(01:44:34)
age what is his self-regulatory age it's
(01:44:37)
30% younger all right that's what you
(01:44:39)
can expect and if you are expecting more
(01:44:41)
than that you're my problem because
(01:44:45)
you're causing the conflict you are like
(01:44:47)
a parent of a dyslexic child demanding
(01:44:49)
normal reading you are like the parent
(01:44:51)
of a mildly child demanding
(01:44:54)
normal self-sufficiency normal cognitive
(01:44:56)
development you're my problem because
(01:44:58)
you just don't get
(01:45:00)
it so I want you to get it it's a 30%
(01:45:05)
lag that's where they're at that's what
(01:45:07)
you can expect if you're asking for more
(01:45:09)
you're going to have to do something to
(01:45:12)
rearrange that environment to allow them
(01:45:15)
to show what they know but if you don't
(01:45:17)
do anything they're going to be about
(01:45:19)
30% behind so what does that mean at 16
(01:45:21)
about giving kids a license
(01:45:25)
are you out of your mind right you just
(01:45:28)
gave an 11-year-old a motor vehicle and
(01:45:31)
you're shocked to see the driving
(01:45:33)
consequences right you may have an
(01:45:35)
18-year-old who's one of the few that's
(01:45:36)
going to go on to college he's 12 that's
(01:45:40)
his executive age how would you have to
(01:45:42)
design a campus if 12year olds were
(01:45:45)
showing up to go to school those are
(01:45:47)
exactly are the accommodations you have
(01:45:49)
got to make on that campus for this
(01:45:51)
person pretend they're 12
(01:45:54)
more handholding more accountability
(01:45:56)
more reporting to Student Services
(01:45:58)
you're going to get more curriculum
(01:46:00)
materials you're going to study in
(01:46:01)
groups with older more competent
(01:46:03)
students you're going to be in a
(01:46:05)
substance-free dorm and you are going to
(01:46:06)
be accountable to Student Services four
(01:46:09)
times a day for the work you're doing in
(01:46:11)
other words we're going to treat you
(01:46:12)
like you're 12 right and then you might
(01:46:14)
just get
(01:46:15)
through but what do we do now we send
(01:46:17)
you off you fail the first semester and
(01:46:19)
everybody Rings their hands of oh what
(01:46:21)
are we going to do we're going to have
(01:46:22)
to change the campus
(01:46:23)
we're going to have to change the
(01:46:25)
environment to suit the executive level
(01:46:27)
not the chronological level so you need
(01:46:30)
to understand the 30% rule because it
(01:46:32)
applies to everything I have a
(01:46:34)
14-year-old daughter with ADHD should
(01:46:36)
she be allowed to babysit are you crazy
(01:46:39)
right this is a 9-year-old being given
(01:46:42)
care of an infant no way I don't care if
(01:46:45)
she finished the Red Cross babysitting
(01:46:47)
course I don't care if she's got a
(01:46:49)
certificate we don't let 9-year-olds
(01:46:52)
attend 3-month old babies
(01:46:55)
unsupervised and that is her executive
(01:46:59)
age you think this is hypothetical we
(01:47:02)
have legal cases of people even into
(01:47:04)
their late teens and 20s who have killed
(01:47:07)
babies out of anger out of impatience
(01:47:10)
out of immaturity out of not knowing
(01:47:13)
what to do when the baby got upset and
(01:47:15)
then their emotion comes to the
(01:47:17)
Forefront so we don't want to go there
(01:47:20)
so you should be looking at all of these
(01:47:22)
Avenues Independence and applying the
(01:47:25)
30% rule to them and that's what you
(01:47:28)
allow and if you are going to give them
(01:47:30)
more you better be doing something to
(01:47:31)
see that they can handle
(01:47:33)
it okay we want you as a parent to
(01:47:36)
understand that every treatment plan has
(01:47:38)
to have these four components or it's
(01:47:40)
not going to work component number one
(01:47:42)
you got to get a good evaluation you
(01:47:45)
have got to see an appropriate
(01:47:47)
knowledgeable professional it doesn't
(01:47:49)
matter whether it's a developmental
(01:47:51)
pediatrician a child psychiatrist a
(01:47:52)
child psychologist or a behavioral
(01:47:54)
neurologist as long as they are well
(01:47:56)
Tred and knowledgeable about ADHD that's
(01:47:59)
the trick it's not the degree it's the
(01:48:02)
knowledge it's the training it's the
(01:48:03)
experience do they see lots of ADHD kids
(01:48:06)
and families or adults so we need an
(01:48:09)
evaluation because 80% of these people
(01:48:11)
have another disorder and that's going
(01:48:13)
to need to be treated as well next
(01:48:16)
families need to educate themselves
(01:48:18)
we'll talk more about that but you need
(01:48:21)
to become an expert about ADHD you're
(01:48:23)
not going to know how to deal with it
(01:48:24)
attending this afternoon has been a big
(01:48:26)
step in that direction third you need to
(01:48:29)
understand that medication is the most
(01:48:30)
effective thing we have and that doesn't
(01:48:33)
matter to me whether you like that or
(01:48:34)
not that is a statement of fact we have
(01:48:38)
no more effective interventions than
(01:48:40)
these medications which is why in the
(01:48:41)
last decade we have moved them up in our
(01:48:43)
priority of using them it used to be
(01:48:46)
that we would try everything else Under
(01:48:47)
the Sun first and only if they failed go
(01:48:50)
to medication well guess what 80% of
(01:48:52)
them failed and we went to medication
(01:48:54)
anyway and we should have started with
(01:48:55)
it to begin with because it would have
(01:48:56)
made them more minimal and more
(01:48:58)
susceptible to the other psychosocial
(01:49:00)
educational programs we were trying to
(01:49:01)
do so don't be surprised to learn that
(01:49:04)
up to 80% of ADHD children will be on
(01:49:07)
medication at some time in their
(01:49:08)
developmental period whether that is
(01:49:10)
childhood or adolescence because there
(01:49:12)
are times and places where you cannot
(01:49:14)
Institute a psychosocial treatment if
(01:49:16)
your child is driving home from the
(01:49:19)
homecoming last night which was over at
(01:49:21)
the Delta hotel by the way I checked and
(01:49:23)
there's a prom going
(01:49:25)
on you can't be there handing out tokens
(01:49:28)
for following the speed limit you know
(01:49:30)
this is idiotic to think that behavioral
(01:49:32)
interventions are as good as medications
(01:49:34)
they're not where they're done when
(01:49:36)
they're done they're good but there are
(01:49:38)
places where they can't be done and now
(01:49:41)
what do we do the medications fill those
(01:49:44)
gaps so that's why we use them and
(01:49:47)
that's why you're seeing medication on
(01:49:49)
the increase in both of our countries
(01:49:51)
and it is completely rational to do so
(01:49:55)
then we make
(01:49:57)
accommodations that's what I meant by
(01:49:58)
altering the points of performance using
(01:50:00)
those five strategies we talked about
(01:50:03)
externalizing information you need to
(01:50:05)
create prosthetic devices in these
(01:50:08)
places to help them show what they
(01:50:14)
know so then as a parent now that you
(01:50:17)
know ADHD and you know that it's a more
(01:50:19)
profound and a more impairing disorder
(01:50:21)
than we once thought what can you do I
(01:50:23)
want you to take three roles and you can
(01:50:24)
read about these in my book taking
(01:50:26)
charge of ADHD the first role every
(01:50:29)
parent should play is to become a
(01:50:31)
scientific parent which means make
(01:50:33)
yourself an expert I want you knowing as
(01:50:35)
much as the professionals know so you
(01:50:38)
should be reading widely because truth
(01:50:40)
is an assembled thing it doesn't come
(01:50:42)
from a single website or Source it comes
(01:50:44)
from integrating across those and seeing
(01:50:47)
the reliable information that keeps
(01:50:49)
showing up across the various sources
(01:50:51)
that you're reading so whether you go to
(01:50:53)
chad. org or add.org or cat.org or the
(01:50:57)
other
(01:50:58)
websites read learn become an expert
(01:51:01)
know as much as you can just like a
(01:51:02)
family of a diabetic child needs to know
(01:51:04)
diabetes inside and out if they're going
(01:51:06)
to appropriately cope with and
(01:51:08)
compensate for that child's diabetes and
(01:51:11)
then just like a scientist you are going
(01:51:12)
to have to experiment there are hundreds
(01:51:14)
of things that you can do but they don't
(01:51:15)
all work for every child so we have to
(01:51:18)
test revise test revise try it does it
(01:51:20)
work if it doesn't let's move on to
(01:51:21)
something else so there's a test revised
(01:51:24)
process about raising an ADHD child
(01:51:26)
you're not going to get it perfect out
(01:51:28)
of the gate and what worked for one
(01:51:30)
parent may not work for your child and
(01:51:32)
somebody may be un concerted but your
(01:51:33)
child's going to need aerol or viance or
(01:51:36)
stratti and the same dose that work for
(01:51:38)
one may not work for the other it is a
(01:51:40)
process of experimenting and letting
(01:51:42)
your child show you which of these
(01:51:45)
things may work for them so be a
(01:51:49)
experiment I tell that because parents
(01:51:51)
come in and they try the token system
(01:51:52)
and it didn't work and they try time out
(01:51:55)
and you know expecting that the first
(01:51:56)
thing out of the gate is going to be
(01:51:57)
successful and it isn't always so you
(01:51:59)
got to keep trying and then I want you
(01:52:02)
to become very skeptical there is a lot
(01:52:04)
of junk knowledge out there especially
(01:52:07)
on the internet you type ADHD into
(01:52:09)
Google which I did this morning 14
(01:52:12)
million
(01:52:14)
replies there is no way a parent can
(01:52:16)
search that for the diamond in the dung
(01:52:19)
Heap
(01:52:21)
so I want you do to become very
(01:52:24)
skeptical if you are not hearing this
(01:52:26)
information reliably across different
(01:52:29)
sources it probably isn't true and if it
(01:52:32)
sounds too good to be true just like
(01:52:34)
financial planning it probably is right
(01:52:38)
so be careful out there there are
(01:52:40)
magnetic mattresses there's copper
(01:52:42)
bracelets there's gko baloba there's
(01:52:44)
omega-3 sixes there's antioxidants like
(01:52:47)
pyy there is so much junk out there
(01:52:49)
there's a clinic in Las Vegas that will
(01:52:51)
diagnose your whole family and give you
(01:52:53)
chips to spend at the
(01:52:55)
casino you know maybe that works I don't
(01:52:58)
know right but you get the point all
(01:53:01)
right there is so much trash out there
(01:53:05)
that it's hard to sort it out so that's
(01:53:07)
why you really need to have your skeptic
(01:53:09)
hat on whenever you're reading anything
(01:53:12)
and you're looking for Reliable
(01:53:14)
information across sources and then you
(01:53:17)
will filter out the
(01:53:19)
gems the next role you need to become an
(01:53:21)
executive parent you need to stop
(01:53:23)
whining suck it up man up and own this
(01:53:25)
disorder in this child this is the
(01:53:28)
hardest thing for families to do they
(01:53:30)
learn about it they read it but they
(01:53:31)
don't necessarily own it there is this
(01:53:34)
sort of if you will reticence that they
(01:53:37)
have internally that I see from time to
(01:53:39)
time where they always hold out this
(01:53:42)
hope that there's some silver bullet out
(01:53:44)
there usually on the internet that if
(01:53:47)
they just tried that all the problems
(01:53:49)
would be solved we could give this up
(01:53:50)
he'd be normal and let's get on with
(01:53:52)
life right and I wish there was the
(01:53:55)
Silver Bullet but there isn't so we tell
(01:53:57)
this to ADHD adults as well it's one
(01:53:59)
thing to know ADHD it's another thing to
(01:54:02)
own your ADHD and to make it a part of
(01:54:06)
who you are it's not all of who you are
(01:54:09)
you may be a gifted artist you may be a
(01:54:10)
comedian you may be a scientist you may
(01:54:12)
be a physician none of that has to do
(01:54:14)
with ADHD ADHD predisposes to no gift
(01:54:19)
but you do have other gifts and other
(01:54:20)
talents at what you are good at so I
(01:54:23)
want you to embrace ADHD as part of who
(01:54:26)
you are but not all of who you are ADHD
(01:54:29)
is a small set of traits out of the more
(01:54:31)
than 400 that you were blessed with so
(01:54:34)
you may be good at lots of other things
(01:54:36)
let's find those other things because
(01:54:38)
they're going to have to compensate for
(01:54:40)
what your ADHD is dragging down but
(01:54:42)
don't ever attribute those other
(01:54:44)
successful Enterprises to your ADHD CU
(01:54:47)
it just ain't so this is no gift but it
(01:54:51)
doesn't mean you don't have other
(01:54:52)
talents that we could use to compensate
(01:54:54)
for it whether you're a good athlete
(01:54:56)
whether you're Michael Phelps whether
(01:54:57)
you're a good comedian whether you're Ty
(01:54:59)
Pennington on America's Extreme Home
(01:55:01)
Makeover who loves to tear down houses
(01:55:03)
since he was a kid and now he does it
(01:55:05)
for a living right all of these are ADHD
(01:55:08)
adults right but their giftedness is not
(01:55:11)
due to their ADHD it was something they
(01:55:14)
found that they did well that could
(01:55:16)
compensate for the problems that their
(01:55:19)
ADHD had caused so becoming an executive
(01:55:22)
parent like becoming an executive adult
(01:55:24)
with ADHD means part of it is I own the
(01:55:27)
disorder my child has this disorder
(01:55:29)
because until you own it you will not
(01:55:30)
advocate for this child and you have got
(01:55:33)
to get out there and Advocate and not
(01:55:35)
let other people take charge of your
(01:55:37)
child that's why I called my book taking
(01:55:39)
charge of ADHD because too many times I
(01:55:41)
went to school conferences and I saw
(01:55:43)
parents sit
(01:55:45)
intimidated by the degree sitting around
(01:55:47)
the table and saying nothing about what
(01:55:50)
was being said in that meeting and I
(01:55:52)
have to remind parents these people work
(01:55:54)
for you you are the taxpayer this is
(01:55:57)
your child you should be running this
(01:55:59)
meeting I want you coming in with a pad
(01:56:01)
and a tape player and I want you turning
(01:56:03)
it on and I want you saying to people
(01:56:05)
I'm not going to be able to take all the
(01:56:06)
notes I want I'm going to record this
(01:56:07)
meeting now let's talk about my son
(01:56:10)
let's start with you you're his Home
(01:56:11)
Room teacher what do you think what's
(01:56:12)
going on here if you have to run the
(01:56:15)
damn meeting and if somebody says
(01:56:17)
something you don't understand like your
(01:56:19)
child's what Johnson
(01:56:20)
psychoeducational IQ was you were stop
(01:56:23)
this meeting cold in its tracks I don't
(01:56:25)
know what you're talking about all right
(01:56:27)
because you're going to see a lot of
(01:56:28)
jargon tossed around by school
(01:56:30)
professionals part of it's just showing
(01:56:32)
off so stop it right if you don't
(01:56:36)
understand it you Advocate and you can't
(01:56:38)
Advocate if you don't know what they're
(01:56:39)
talking about and then the final
(01:56:41)
decisions are always yours whatever the
(01:56:44)
list of recommendations are because
(01:56:46)
sometimes the recommendations don't fit
(01:56:48)
your child this is just a list of
(01:56:50)
recommendations that apply to ADHD plain
(01:56:52)
vanilla and you may not have plain
(01:56:54)
vanilla so you're going to have to look
(01:56:56)
at those you know your child better than
(01:56:58)
anybody else and you will pick and
(01:56:59)
choose from those the ones you believe
(01:57:02)
are most suitable to your family to your
(01:57:04)
child to your values and so on but you
(01:57:07)
run the meeting and you don't sign off
(01:57:10)
on anything that you are not comfortable
(01:57:11)
with I love parents who come in and give
(01:57:14)
me grief I do not like parents who come
(01:57:17)
in and sit like a bunch of milk toast
(01:57:19)
sitting in an office and just listening
(01:57:21)
listening listening and not asking
(01:57:23)
questions and not advocating and not
(01:57:25)
telling me I don't think that's going to
(01:57:26)
work his grandparents are not going to
(01:57:28)
buy conserta they're going to take us to
(01:57:30)
court for child abuse you got to help me
(01:57:32)
with that that's a true story and that
(01:57:33)
comes from my nephew so consequently
(01:57:36)
families need to speak up how do I know
(01:57:39)
that your grandparents are resistant to
(01:57:41)
medication and that they will make your
(01:57:42)
life miserable if you don't tell me okay
(01:57:45)
now I can tell you how to help the
(01:57:47)
grandparents but you see if the parent
(01:57:49)
doesn't talk up I don't know I can't
(01:57:51)
help you cope with that role number two
(01:57:54)
Advocate number three if you ever read
(01:57:56)
cuvies the seven habits are Highly
(01:57:58)
Effective People you better in fact the
(01:58:00)
better book is the seven habits are
(01:58:02)
highly affective families because we
(01:58:04)
have found that more than any other
(01:58:06)
families families raising disabled
(01:58:08)
children really need to learn and
(01:58:11)
utilize these cvy has at the back of the
(01:58:14)
book a diagram that looks like an
(01:58:15)
hourglass that has all seven principles
(01:58:18)
built into these two upside down
(01:58:20)
triangles photocopy it and tape it to
(01:58:23)
your bathroom mirror when you are
(01:58:25)
putting on your makeup or shaving in the
(01:58:26)
morning I want those seven habits in the
(01:58:28)
corner of your visual field that is your
(01:58:31)
morning reminder to try to get it
(01:58:34)
right I do that you should do that and I
(01:58:37)
didn't raise ADHD children but these are
(01:58:40)
very good principles for interpersonal
(01:58:43)
relationships and especially if you have
(01:58:45)
a disabled child so if you're not
(01:58:47)
familiar with it these are the seven
(01:58:48)
principles you can read more about them
(01:58:51)
now once you have adopted these three
(01:58:54)
roles there is another role I would like
(01:58:56)
you to assume and this I think just
(01:58:58)
Paints the whole picture this is sort of
(01:59:00)
the background canvas on which you paint
(01:59:02)
the rest of this portrait you need to
(01:59:06)
understand something that parents these
(01:59:07)
days have long since forgot and are
(01:59:09)
going to have to relearn again your
(01:59:11)
grandparents knew this but today's
(01:59:13)
generation of parents doesn't seem to
(01:59:16)
and that is you do not get to design
(01:59:18)
your children nature would never have
(01:59:21)
permitted that to happen
(01:59:23)
Evolution would not have allowed a
(01:59:25)
generation of a species to be so
(01:59:28)
influenced by the previous generation it
(01:59:30)
hasn't happened and it doesn't happen
(01:59:32)
and it especially doesn't happen in
(01:59:34)
children you do not design your children
(01:59:38)
and yet we have the Mozart effect the
(01:59:39)
belief that if I play classical music to
(01:59:41)
my uterus when I'm pregnant I'm going to
(01:59:43)
have a genius the fact that if I can
(01:59:45)
just put enough crib toys over his crib
(01:59:48)
he is going to have all these neurons
(01:59:50)
exploding with synapses and be a
(01:59:53)
brilliant mathematician you don't get
(01:59:56)
that degree of power right does that
(01:59:59)
mean stimulation doesn't matter no it
(02:00:01)
means a stimulation environment is
(02:00:03)
better than a deprived environment but
(02:00:05)
it doesn't mean that the more
(02:00:06)
stimulation you add into the environment
(02:00:08)
the better it gets it's a threshold
(02:00:10)
there is enough stimulation that every
(02:00:11)
normal brain needs to develop and once
(02:00:13)
you're past that which 98% of you are
(02:00:16)
the rest of it is out of your
(02:00:18)
hands but this idea that if a little bit
(02:00:21)
is good a ton of it must be better is a
(02:00:23)
uniquely North American perspective
(02:00:25)
right believe me the French don't look
(02:00:27)
as kindly on their children as we do
(02:00:29)
right that's another story for another
(02:00:36)
day so what we have learned in the last
(02:00:39)
20 years of research in neuroimaging
(02:00:41)
Behavior genetics developmental
(02:00:43)
psychology neuros pychology can be
(02:00:44)
boiled down to this phrase your child is
(02:00:48)
born with more than 400 psychological
(02:00:51)
traits
(02:00:52)
that will emerge as they mature and they
(02:00:56)
have nothing to do with
(02:00:58)
you so the idea that you are going to
(02:01:01)
engineer personalities and IQ and
(02:01:03)
academic achievement skills and all
(02:01:05)
these other things just isn't true your
(02:01:08)
child is not a blank slate on which you
(02:01:11)
get to write if you would like to read
(02:01:13)
more about this please read Steven
(02:01:15)
pinker's book the blank slate which is a
(02:01:18)
review of all of this information for
(02:01:19)
parents and why it isn't true the the
(02:01:22)
better view is that your child is a
(02:01:24)
genetic Mosaic of your extended family
(02:01:28)
which means this is a unique combination
(02:01:31)
of the traits that run in your family
(02:01:34)
line I like the shepherd view you are a
(02:01:37)
Shepherd you don't design the Sheep the
(02:01:39)
engineering view makes you responsible
(02:01:41)
for for everything everything that goes
(02:01:44)
right and everything that goes wrong
(02:01:45)
this is why parents come to us with such
(02:01:47)
guilt more guilt than we've ever seen in
(02:01:49)
Prior Generations because parents today
(02:01:52)
believe that it's all about them and
(02:01:54)
what they do and if they don't get it
(02:01:56)
right or if their child has a disability
(02:01:58)
they've done something wrong when in
(02:02:01)
fact the opposite is true this has
(02:02:03)
nothing to do with your particular brand
(02:02:05)
of parenting so I would rather that you
(02:02:08)
stop thinking yourself as an engineer
(02:02:10)
and step back and say I am a Shepherd to
(02:02:12)
a unique
(02:02:14)
individual shepherds are powerful people
(02:02:17)
they pick the pastures in which the
(02:02:18)
Sheep will graze and develop and grow
(02:02:21)
they determine whether appropriately
(02:02:23)
nourished they determine whether they're
(02:02:24)
protected from harm the environment is
(02:02:27)
important but it doesn't design the
(02:02:29)
Sheep No Shepherd is going to turn a
(02:02:31)
sheep into a dog ain't going to happen
(02:02:33)
right and yet that is what we see
(02:02:35)
parents trying to do all the time and
(02:02:37)
especially parents of children with
(02:02:39)
disabilities so step back and view
(02:02:42)
yourself as the shepherd to this
(02:02:43)
disabled youngster and you get to design
(02:02:46)
the pasture and that's very important
(02:02:48)
but you don't engineer the Sheep now
(02:02:50)
that comes with it a profound L freeing
(02:02:53)
view of parenting because what it means
(02:02:56)
is although it's important to be a
(02:02:58)
Shepherd recognizing that this is a
(02:03:00)
unique individual before you allows you
(02:03:03)
to enjoy the show right so open a bottle
(02:03:06)
of chardonay kick off your slippers sit
(02:03:08)
back and watch what takes place right
(02:03:12)
because you don't get to determine this
(02:03:14)
right so enjoy it it doesn't last all
(02:03:15)
that long anyway they're gone before you
(02:03:17)
know it right but if you think that what
(02:03:20)
you did in your house is going to shape
(02:03:21)
the life for of this individual you are
(02:03:23)
sadly mistaken right this is a unique
(02:03:27)
individual let them grow let them
(02:03:29)
Prosper please design appropriate
(02:03:30)
environments around them but you don't
(02:03:32)
get to design them as Judy Harris said
(02:03:35)
in 1996 in the first book on this
(02:03:37)
subject written for Lay people the book
(02:03:39)
is called the nurture assumption as she
(02:03:42)
said you had more to do with your
(02:03:44)
child's life by where you chose to live
(02:03:46)
than by anything you will ever do inside
(02:03:48)
that home short of abuse neglect or
(02:03:51)
malut ntion the rest of it is just
(02:03:54)
trivial variation it's where you live
(02:03:58)
why because outof home influences are
(02:04:01)
more powerful in shaping the life course
(02:04:03)
of your child than inhome influences are
(02:04:07)
and those out of home influences are
(02:04:09)
peer groups other adults neighborhoods
(02:04:13)
resources schools and the larger
(02:04:16)
community that you made available to
(02:04:18)
this child that is how you shape your
(02:04:20)
child's life course the second biggest
(02:04:22)
influence is also out of your hands and
(02:04:25)
That's genetics and you don't get to
(02:04:27)
determine that but if you think
(02:04:29)
parenting is so influential let me give
(02:04:31)
you two findings that have been
(02:04:32)
replicated many times when we follow up
(02:04:35)
twins we are able to calculate how much
(02:04:37)
of their behavior is due to Parenting
(02:04:39)
within family environment and here's
(02:04:41)
what we find the peak years of Parental
(02:04:44)
influence are below seven from 7 on to
(02:04:47)
12 it drops dramatically after 15 it's
(02:04:50)
6% 6% of the variation in a teenager's
(02:04:54)
behavior is how their parents raise them
(02:04:56)
that's it and after age 21 it's zero
(02:04:59)
there is no influence of parenting on
(02:05:01)
any psychological trait after the age of
(02:05:03)
21 now do not mistake what I am saying
(02:05:07)
the knowledge your child possesses what
(02:05:10)
they know is clearly a function of
(02:05:12)
exposure in the environment but their
(02:05:15)
traits their abilities their makeup
(02:05:17)
their personality is not so the idea
(02:05:21)
that somehow we design these kids and we
(02:05:23)
can get rid of ADHD needs to be
(02:05:25)
abandoned the other research finding is
(02:05:27)
the following and it has been found in
(02:05:29)
every single study there is no
(02:05:31)
correlation between any trait of an
(02:05:32)
adopted child and the people who raised
(02:05:34)
them
(02:05:36)
none if you think parenting is so
(02:05:38)
powerful prove it otherwise step back
(02:05:42)
accept your role as a Shepherd do it
(02:05:45)
well and enjoy the show it's going to be
(02:05:48)
a unique set of fireworks I guarantee
(02:05:50)
you that
(02:05:52)
but now not only do you not get the
(02:05:54)
credit you also don't have to take the
(02:05:56)
blame you didn't cause this ADHD or
(02:05:59)
whatever other disability your child
(02:06:01)
has your child because of the executive
(02:06:04)
deficit is going to need to be made more
(02:06:06)
accountable to others we've already
(02:06:07)
talked about a lot of this but let's
(02:06:09)
just go back over it in more specifics
(02:06:11)
first you need to be much more
(02:06:13)
consistent with your rules and
(02:06:14)
consequences in raising this child than
(02:06:16)
normal parents need to be and that's not
(02:06:19)
because you're going to engineer the
(02:06:20)
ADHD out of the child it's because
(02:06:22)
you're going to make this child less
(02:06:24)
disabled from their ADHD by doing that
(02:06:27)
ADHD is not information Deficit Disorder
(02:06:29)
so kindly shut up act don't yak the more
(02:06:34)
you blather the more you n the more you
(02:06:36)
nag the less influence you have so stop
(02:06:39)
thinking that one more sentence will be
(02:06:41)
enough to tip the scales in favor of
(02:06:44)
obedience it isn't right if I can just
(02:06:47)
say it one more time I know he'll listen
(02:06:50)
so on the 20th time there you are
(02:06:52)
fingers crossed behind your back okay so
(02:06:55)
say it once then back it up what these
(02:06:58)
kids listen to more than anything are
(02:06:59)
the immediate consequences not the Ning
(02:07:01)
not the nagging not the moral essays and
(02:07:04)
why you should clean up your room to
(02:07:05)
avoid
(02:07:08)
menitis now with ADHD children you've
(02:07:11)
got to get their attention one of the
(02:07:12)
easiest ways to do it and also an
(02:07:14)
affectionate way is to touch them so I
(02:07:17)
want you to put your hand on their arm
(02:07:18)
on their hand or around their
(02:07:20)
shoulder when you you talk to them I
(02:07:22)
want you to look in their eye and with
(02:07:24)
that Clint Eastwood
(02:07:26)
look I want you to keep it short and
(02:07:28)
sweet what do you want done what are you
(02:07:30)
trying to say or is this positive
(02:07:33)
feedback is this approval is this
(02:07:35)
recognition is this praise but touch
(02:07:38)
then talk keep it short keep it sweet
(02:07:41)
get to the point and then back it up all
(02:07:44)
right if you're a parent with an ADHD
(02:07:46)
child you better be setting a timer to
(02:07:47)
go off every few minutes and check on
(02:07:49)
where that child is this is to avoid
(02:07:51)
accident injury it is also to catch
(02:07:54)
problems before they occur in order to
(02:07:56)
be a proactive parent and I'll show you
(02:07:59)
what we call the transition plan in a
(02:08:01)
moment I want you to increase the
(02:08:02)
frequency of consequences for this child
(02:08:04)
your child needs much more external
(02:08:06)
consequences than other people so
(02:08:09)
there's no need to apologize for it
(02:08:10)
you're not going to turn them into some
(02:08:12)
little materialistic kid because he
(02:08:13)
already is
(02:08:17)
anyway
(02:08:20)
okay okay here's one he's got a short
(02:08:23)
attention span du break the work into
(02:08:26)
small pieces stop trying to torture his
(02:08:29)
attention span to become longer than it
(02:08:32)
possibly could ever be so remember the
(02:08:34)
30% rule reduce the age by 30% that's
(02:08:37)
his attention span I have to cut the
(02:08:39)
work into that short a period so instead
(02:08:42)
of 30 problems all at once you get
(02:08:45)
five then you do them bring them up to
(02:08:47)
me I will take a pair of scissors and
(02:08:48)
snip off the next five math problems and
(02:08:50)
give them back to you this this is how
(02:08:52)
you're going to take exams this is how
(02:08:53)
you're going to do your work small
(02:08:55)
chunks frequent breaks not one chunk all
(02:08:59)
it once by the way that is better than
(02:09:02)
giving extra time on an exam even to a
(02:09:04)
college student extra time on an exam to
(02:09:06)
someone with no sense of time is a dumb
(02:09:10)
idea you stole that from the learning
(02:09:12)
disabilities because you didn't know
(02:09:13)
what the heck else to ask for so I guess
(02:09:15)
we'll just ask for extra time well extra
(02:09:17)
time to somebody with this disorder is
(02:09:19)
the definition of hell you want to know
(02:09:21)
why because if you have no sense of time
(02:09:23)
I want you to remember back to when you
(02:09:25)
were five and it was the week before
(02:09:26)
Christmas what did that feel like huh
(02:09:29)
like molassus this slow moving well
(02:09:32)
that's what it feels like to somebody
(02:09:33)
with ADHD and you just gave them an
(02:09:36)
extra hour oh
(02:09:39)
great they're up they're out they're out
(02:09:42)
the door before you even know it I love
(02:09:43)
this extra time recommendation because
(02:09:45)
it's so stupid
(02:09:47)
right what you should be doing is called
(02:09:50)
time off the clock
(02:09:52)
you get a stopwatch on that stopwatch is
(02:09:55)
going to be the length of time everybody
(02:09:57)
else gets start the watch and anytime
(02:10:00)
you like you can stop it stand up
(02:10:03)
stretch take a break ask me a question
(02:10:05)
come back start the watch you will only
(02:10:08)
get the same hour as everybody else but
(02:10:10)
you get to break it up as often as you
(02:10:11)
like will this take extra time of course
(02:10:15)
but that is merely a byproduct of the
(02:10:17)
strategy whereas telling somebody they
(02:10:20)
have extra time is not a strategy
(02:10:23)
this is being done throughout the entire
(02:10:24)
state of Indiana by the educational
(02:10:26)
testing service to prove that it is a
(02:10:27)
more compelling accommodation for taking
(02:10:30)
multiple choice time tests than is the
(02:10:32)
old extra time which we already know is
(02:10:35)
going to fail anyway break the work into
(02:10:38)
pieces more frequent breaks the work
(02:10:40)
will get done you are going to have to
(02:10:42)
use external timers we've already talked
(02:10:44)
about that now we want you to become
(02:10:46)
proactive not just in monitoring where
(02:10:47)
your kids are but also in transitioning
(02:10:51)
across activities so that when you are
(02:10:54)
making a major change in what your
(02:10:56)
family is doing with this child I want
(02:10:58)
you to
(02:11:00)
stop so everything stops okay hold your
(02:11:02)
horses wait a second It's homework time
(02:11:05)
so turn off the TV stop the action and
(02:11:09)
then I want you to review two or three
(02:11:10)
rules this child is to follow in the
(02:11:12)
next activity then I want you to set up
(02:11:15)
what is the incentive what's in it for
(02:11:16)
him what are you offering
(02:11:18)
points tokens privileges extra time on
(02:11:22)
Nintendo or Game Boy or Wii or whatever
(02:11:24)
what are you offering right next what's
(02:11:27)
the punishment what's he going to lose
(02:11:29)
make it clear you're going to lose that
(02:11:30)
privilege you're going to lose those
(02:11:32)
points you're going to lose that time on
(02:11:33)
that computer or you're going to time
(02:11:35)
out make it obvious get the rules
(02:11:38)
upfront along with the consequences okay
(02:11:41)
now I want you to distribute the
(02:11:42)
consequences throughout the task you
(02:11:45)
don't wait till it's over there should
(02:11:46)
be rewards every so often during the
(02:11:49)
task or they'll never finish then I want
(02:11:51)
you to review with them what do you
(02:11:53)
think how did you do how could we do
(02:11:55)
this better get their opinion invite
(02:11:57)
them to self- evaluate the activity if
(02:12:00)
you will do that you will cut your
(02:12:01)
problems by 50% what do most parents and
(02:12:03)
teachers do they do reactive parenting
(02:12:06)
you go about minding your own business
(02:12:07)
doing your laundry fixing dinner until
(02:12:09)
the problem occurs and now you are a
(02:12:12)
problem oriented person all you're doing
(02:12:14)
is reactive firefighting we call it had
(02:12:17)
you just set your plan up front whether
(02:12:20)
it's before you go into a store or a
(02:12:22)
restaurant or you start homework or we
(02:12:24)
go to recess or we have friends visit or
(02:12:26)
we go in Grandma's house every one of
(02:12:29)
those is a major transition you need to
(02:12:30)
stop and do Transition
(02:12:33)
planning now what are you going to do
(02:12:35)
when your child is not with you you're
(02:12:37)
going to get a behavior monitoring card
(02:12:38)
like the kind we use for school but this
(02:12:40)
can be used anywhere anytime it can be
(02:12:42)
used for Cub Scouts Little League Soccer
(02:12:45)
hockey going to a friend's house
(02:12:47)
spending the afternoon or evening or
(02:12:48)
weekend with grandparents having a
(02:12:50)
babysitter any place this kid is going
(02:12:52)
to be and you're not there you can
(02:12:54)
monitor it with a monitoring card in the
(02:12:57)
case of school you're going to use these
(02:12:59)
rules and there's enough room for all of
(02:13:01)
his teachers and classes to evaluate him
(02:13:03)
using the rating at the top of the card
(02:13:05)
1 through five when this card comes home
(02:13:08)
from school every teacher will have
(02:13:09)
raided this child at the end of every
(02:13:11)
class will have initialed it to assure
(02:13:13)
against forgeries because they will
(02:13:15)
Forge this
(02:13:17)
card so let's anticipate that all right
(02:13:21)
and then the parents are going to review
(02:13:22)
the card and the points are in
(02:13:23)
parentheses that's how many points you
(02:13:25)
earn and in the case of fours and fives
(02:13:26)
which are lousy ratings that's how many
(02:13:28)
points you lose you are then going to
(02:13:30)
add up the point subtract the negatives
(02:13:32)
that's what you got to spend in your
(02:13:34)
home on your little token system on your
(02:13:37)
reward chart but you could do this for
(02:13:39)
anything it could be for bus rides it
(02:13:41)
could be for lunchroom it can be for
(02:13:42)
recess it can be for Scouts I don't care
(02:13:45)
if he is away from you and there's
(02:13:47)
another adult there that other adult can
(02:13:49)
be evaluating your child frequently
(02:13:51)
whether it's every 15 minutes whether
(02:13:53)
it's at the end of every 45 minute class
(02:13:54)
period as it is in school doesn't matter
(02:13:57)
frequent evaluation comes back to you
(02:14:00)
you deliver the full consequences based
(02:14:02)
on that card and here again you can
(02:14:04)
start to cut down Problems by increasing
(02:14:07)
accountability even in places where you
(02:14:15)
can all right we've talked about the
(02:14:17)
behavioral adjustments we've talked
(02:14:19)
about how to make these changes at the
(02:14:20)
point of performance but let's also face
(02:14:23)
it by themselves they're not enough only
(02:14:26)
a third of ADHD children respond enough
(02:14:29)
to those changes to not need medication
(02:14:32)
and even many of those would still
(02:14:34)
benefit from their medication but 2third
(02:14:37)
and in my experience it's as many as 80%
(02:14:40)
are going to have to go on medication at
(02:14:42)
some point in life maybe it's not this
(02:14:45)
month maybe it'll be in 6 months maybe
(02:14:47)
it's a year just depends on how
(02:14:49)
compassionate and Cooperative the care
(02:14:51)
givers happen to be and of course how
(02:14:53)
severe the ADHD happens to be as well
(02:14:56)
but at some point these medications will
(02:14:58)
be needed for most children so I want
(02:15:00)
parents to know them and to know about
(02:15:02)
them now if you're looking for a very
(02:15:04)
good book the single best book for
(02:15:05)
parents on psychiatric drugs is by Dr
(02:15:07)
Timothy willins straight talk about
(02:15:10)
psychiatric medication for children you
(02:15:12)
can get it at the add Warehouse you can
(02:15:14)
get it through Guilford Publications at
(02:15:21)
book on
(02:15:23)
psychopharmacology straight talk about
(02:15:26)
psychiatric medication for children so
(02:15:29)
quickly let's go over what's out there
(02:15:32)
right first of all parents need to know
(02:15:34)
we have stimulants there are only two
(02:15:36)
now we have had them since 1936 for the
(02:15:39)
amphetamines and 1957 for
(02:15:41)
methylphenidate they've been around a
(02:15:43)
long time which means we know a lot
(02:15:46)
about them we know how safe and
(02:15:48)
effective they are these are the best
(02:15:50)
studied drugs used in Pediatrics and
(02:15:52)
Psychiatry so parents need to understand
(02:15:54)
that we got a lot of information out
(02:15:56)
there on the safety and effectiveness of
(02:15:58)
these agents but there still is only two
(02:16:01)
stimulants the news in the last seven or
(02:16:04)
eight years has been in the Delivery
(02:16:06)
Systems because the problem with the
(02:16:08)
immediate release medications is they
(02:16:10)
only lasted three or 4 hours so they had
(02:16:12)
to be given two to three times a day so
(02:16:14)
you had to take them at school and that
(02:16:15)
created all kinds of problems so
(02:16:18)
companies went back and re-engineered
(02:16:20)
Delivery Systems to try to keep the
(02:16:21)
drugs in the body for longer periods of
(02:16:24)
time on a single dose and they came up
(02:16:26)
with four ingenious Delivery Systems
(02:16:28)
called the five PS which I will tell you
(02:16:30)
about in just a
(02:16:32)
moment let's also understand that last
(02:16:34)
year was published the biggest study
(02:16:36)
ever done a stimulant safety for
(02:16:38)
preschool children with ADHD and they
(02:16:40)
show that the drugs are effective and
(02:16:42)
are safe down to age two so the fact
(02:16:45)
that we are seeing some of these drugs
(02:16:47)
instituted younger in life than
(02:16:49)
previously is nothing to worry about it
(02:16:52)
looks okay the preschoolers don't
(02:16:55)
respond quite as well but apart from
(02:16:58)
that there are no new side effects and
(02:17:00)
there's certainly nothing
(02:17:00)
life-threatening about using them the
(02:17:03)
other new agent we have out there is
(02:17:05)
atomoxetine this is stratera approved in
(02:17:07)
2003 in the US and about a year later
(02:17:09)
here in Canada stratera is not a
(02:17:12)
stimulant it is not an abusable
(02:17:14)
drug uh and it is nearly as effective
(02:17:17)
though not quite as effective as the
(02:17:20)
stimulants but for some children with
(02:17:21)
particular uh ADHD comorbidities like
(02:17:24)
ticks anxiety tourettes OCD insomnia and
(02:17:29)
so forth atomoxetine can be a good
(02:17:31)
alternative drug because it doesn't
(02:17:33)
worsen those comorbid conditions now you
(02:17:36)
should also be aware that this August
(02:17:38)
the us will have a new drug on the
(02:17:40)
market for ADHD it will be guanfacine XR
(02:17:43)
guanosine XR will be called intuniv this
(02:17:47)
is not a stimulant this is an
(02:17:49)
anti-hypertensive drug it has been been
(02:17:51)
used for years with ADHD children
(02:17:53)
especially if they have Tourette
(02:17:54)
Syndrome or bipolar disorder or very
(02:17:57)
explosive behavior because the
(02:17:59)
anti-hypertensive drug appears to help
(02:18:01)
lower emotional impulsive behavior in
(02:18:05)
the individual but Shire has now been
(02:18:07)
able to manufacture a long acting
(02:18:10)
version of guanfacine previously called
(02:18:12)
tenx and it will be marketed under the
(02:18:15)
Guan facine label I expect that you guys
(02:18:17)
will probably see it a year or two after
(02:18:19)
we get it now let's go back to the five
(02:18:22)
PS these are the new Delivery Systems
(02:18:25)
the first p is the pellet system excuse
(02:18:27)
me the pill system my apologies the
(02:18:30)
pills are the original forms of the drug
(02:18:32)
rlin and dexadrin are in their original
(02:18:34)
pill form they last about 3 to 5 hours
(02:18:37)
so what's new they put him in a pump
(02:18:40)
this is Concerta conserta is a miniature
(02:18:43)
hydraulic pump so that when you swallow
(02:18:46)
this there is powdered rlin on the
(02:18:48)
outside of this little capsule and it
(02:18:51)
goes to work immediately and then on one
(02:18:53)
end of this capsule barely visible to
(02:18:55)
you is a laser H drilled hole at the end
(02:18:58)
of the capsule inside the capsule is a
(02:19:00)
methylphenidate sludge in two doses a
(02:19:03)
light dose at the beginning double the
(02:19:05)
dose in the afternoon when you swallow
(02:19:08)
this water is going to come into this
(02:19:09)
upper chamber at a continuous rate and
(02:19:11)
it's going to push down on this and like
(02:19:13)
a tube of toothpaste it's going to
(02:19:14)
squeeze liquid ridling out for about 10
(02:19:16)
to 12 hours that is really neat and then
(02:19:20)
the pill is secreted um in the the
(02:19:23)
child's uh excrement so you've got a
(02:19:25)
drug that can last around 10 hours some
(02:19:28)
kids it's only8 others get as much as 12
(02:19:30)
but about 8 to 10 is about right that is
(02:19:32)
a really neat system the next system is
(02:19:36)
the time release pellet system so we've
(02:19:39)
got the pill the pump and now the pellet
(02:19:42)
the time release pellets are what
(02:19:43)
adderal XR involves Focalin uh La I
(02:19:48)
think or XR rlin La they're all time
(02:19:50)
relase p
(02:19:52)
and guanosine XR is going to be the same
(02:19:54)
way so you have different pellets of
(02:19:56)
medication in this case amphetamine
(02:19:58)
they're coated with different time
(02:19:59)
release Coatings some dissolve right
(02:20:01)
away some in an hour 2 3 4 up to 8 to 10
(02:20:05)
hours so is there any difference between
(02:20:08)
the pellet system and the pump not
(02:20:10)
really over the day but on the time of
(02:20:13)
day there is the pellet system is better
(02:20:16)
if the problems are greatest in the
(02:20:17)
morning the pump system is greater or
(02:20:19)
better if the problems are toward the
(02:20:21)
afternoon or late in the day but other
(02:20:24)
than that across the day they cover
(02:20:25)
about 8 to 10 hours excuse me I want to
(02:20:28)
get rid of
(02:20:30)
that okay hold on the next p I don't
(02:20:33)
know if you have this up here in
(02:20:35)
Canada this is the patch okay this is
(02:20:37)
day Trana this is methylphenidate in a
(02:20:40)
skin patch wear it on the buttocks wear
(02:20:42)
it on your shoulder on your hip wear it
(02:20:44)
all day long that's it it's absorbed
(02:20:46)
through the skin no taking pills this is
(02:20:48)
a very hard drug to abuse because you
(02:20:50)
can't can't snort the patch
(02:20:54)
right but there's a problem about 15 to
(02:20:57)
18% of patients develop a skin rash to
(02:21:00)
this and can't tolerate it and it's due
(02:21:01)
to the drug but 80 84% of the people can
(02:21:05)
tolerate the skin patch so it's pretty
(02:21:07)
good as an alternative oh by the way I
(02:21:09)
meant to mention under the pellet system
(02:21:11)
one of its advantages is if a child
(02:21:13)
can't swallow a pill and you don't have
(02:21:14)
the patch available you can open the
(02:21:17)
capsule and sprinkle the pellets on food
(02:21:20)
like on yogurt or applesauce doesn't
(02:21:22)
change the delivery at all um so that's
(02:21:25)
another advantage of that finally last
(02:21:27)
August we have the first drug of its
(02:21:29)
kind ever produced this is viance It's a
(02:21:32)
form of amphetamine it's called a
(02:21:34)
prodrug hence the last P what is a prod
(02:21:37)
drug a prod drug is where you take a
(02:21:39)
chemical in this case amphetamine and
(02:21:42)
you lock it up okay this is the
(02:21:44)
amphetamine right here and you lock it
(02:21:47)
up with another chemical so it can't
(02:21:49)
work
(02:21:51)
now this drug will only work after you
(02:21:53)
split off in this case the
(02:21:56)
lizine you swallow viance there's a
(02:21:59)
chemical in your body that will split
(02:22:01)
off the lizine and now the amphetamine
(02:22:03)
can go to work this is the first non-
(02:22:06)
abusable amphetamine ever invented
(02:22:08)
because it only works in the stomach and
(02:22:11)
after it crosses through the intestine
(02:22:12)
into the bloodstream and that's where
(02:22:15)
the chemical is the enzyme that splits
(02:22:18)
off the lizine and now it goes to work
(02:22:21)
so we have a non- abusable amphetamine
(02:22:23)
on the market in the US I don't know if
(02:22:25)
you have viance yet it's probably coming
(02:22:27)
this year I believe okay so just be
(02:22:31)
aware that it's down there viance is a
(02:22:33)
little better than adero XR which is the
(02:22:35)
Other Drug made by the same company and
(02:22:37)
it's replacing it in the US because
(02:22:39)
viance last 2 hours longer than the
(02:22:43)
other drugs do this is about a 12h hour
(02:22:47)
drug it also has a softer onset and a
(02:22:50)
softer
(02:22:51)
offset unlike Aderall so it's a pretty
(02:22:54)
good drug I want parents to understand
(02:22:56)
there are misconceptions of foot about
(02:22:59)
the stimulants they are not addictive as
(02:23:01)
prescribed unless you inject or inhale
(02:23:03)
them they do not produce aggression and
(02:23:05)
they didn't cause Coline they are in
(02:23:07)
fact able to reduce aggressive and
(02:23:09)
antisocial Behavior they do not cause
(02:23:12)
seizures you'd have to swallow the whole
(02:23:14)
bottle so even children with seizure
(02:23:16)
disorders can take these drugs safely
(02:23:18)
they do not cause ticks or Tourette
(02:23:21)
unless you already are prone to ticks or
(02:23:24)
tourettes and then they may bring them
(02:23:25)
out and make them worse even then only
(02:23:28)
in about 30% of the cases the remaining
(02:23:30)
cases do not experience a worsening them
(02:23:33)
of their ticks and so children with ADHD
(02:23:35)
and ticks can take these drugs safely as
(02:23:37)
long as they're not one of the 30% that
(02:23:39)
makes it worse and by the way the
(02:23:40)
worsening is temporary stop the drug the
(02:23:43)
ticks will go back to their Baseline
(02:23:44)
within a week are we overdosing ADHD
(02:23:47)
children in North America absolutely not
(02:23:51)
if you look at the prevalence of the
(02:23:52)
disorder it's 7 and a half percent if
(02:23:55)
you look at how many children are taking
(02:23:56)
medication it's between four and 5%
(02:23:59)
which means you are missing a third of
(02:24:01)
all children and by the way 90% of all
(02:24:04)
adults with ADHD are not
(02:24:07)
treated so are we using more medication
(02:24:09)
than ever before yes is it scandalous no
(02:24:13)
what's our problem we still have people
(02:24:14)
who don't have access to care and who
(02:24:16)
aren't being treated for their disorder
(02:24:18)
and that's the real problem as our
(02:24:20)
Surgeon General pointed out not overt
(02:24:22)
treatment in the United States or up
(02:24:26)
here is there a risk of later substance
(02:24:29)
abuse from the stimulants your own CBC
(02:24:32)
ran a program on marketpl Marketplace is
(02:24:35)
that what it's called right the one with
(02:24:36)
that little blonde hottie that used to
(02:24:38)
date your Member of
(02:24:40)
Parliament I just want to make sure I
(02:24:42)
got the right program that's all
(02:24:44)
everybody knows when I say that oh her
(02:24:46)
yeah we know okay I have a bone to pick
(02:24:49)
with that because they were in fact uh
(02:24:52)
deceitful in their creation of that
(02:24:55)
program especially with our medical
(02:24:57)
school but nevertheless they rent a
(02:24:59)
program claiming that stimulants can
(02:25:01)
predispose children to cocaine abuse
(02:25:03)
nicotine and Other Drugs of abuse later
(02:25:05)
in life if your children took them this
(02:25:07)
was based upon a single study done by
(02:25:09)
naen Lambert in San
(02:25:11)
Francisco naen study has many many flaws
(02:25:14)
in it not the least of which is she
(02:25:16)
never control for conduct disorder which
(02:25:17)
is the biggest predictor of drug abuse
(02:25:19)
among ADHD children and when you control
(02:25:21)
for that there is no link between being
(02:25:24)
treated with a stimulant and abusing any
(02:25:26)
drug how do I know that because 17 you
(02:25:29)
can correct this slide 17 studies
(02:25:31)
including my own have now shown no
(02:25:34)
relationship between length of time you
(02:25:36)
take a stimulant throughout childhood
(02:25:38)
and risk of any abuse in adulthood so
(02:25:41)
there's your box score 17 to1 what did
(02:25:43)
the CBC focus on the one why because we
(02:25:47)
all know now that televised journalism
(02:25:50)
is a form of
(02:25:52)
entertainment not a form of information
(02:25:55)
that they go after the Scandal the
(02:25:58)
underbelly The Sensational side and they
(02:26:01)
ignore anything that does not fit that
(02:26:03)
preconceived idea and that's exactly
(02:26:05)
what the CBC did which was I think a
(02:26:07)
travesty of
(02:26:09)
Journalism do they improve academic
(02:26:11)
achievement no not at the start but we
(02:26:15)
now have several studies including one
(02:26:16)
published a week ago that showed that if
(02:26:19)
you stay in your medication at least 2
(02:26:20)
years or more we do start to see an
(02:26:22)
uptick in academic achievement skills
(02:26:24)
but prior to that time what the drugs
(02:26:26)
are doing is improving your productivity
(02:26:29)
the amount of work you do but there's no
(02:26:31)
knowledge in a pill so why would you
(02:26:34)
know your multiplication tables when you
(02:26:36)
take your Concerta when you didn't know
(02:26:37)
them the day before right but what the
(02:26:40)
drugs do is to make you available for
(02:26:43)
Learning and if you stay available for
(02:26:45)
learning over a long enough period of
(02:26:47)
time you do learn more but not in the
(02:26:49)
short run
(02:26:51)
and then I mentioned stratti I'm not
(02:26:52)
going to go over that because I've
(02:26:54)
already mentioned it but it is the
(02:26:55)
non-stimulant on the market right now
(02:26:57)
and as I said we will have another one
(02:26:59)
later on it's a very good drug
(02:27:01)
especially for kids who have anxiety or
(02:27:03)
tick or OCD or insomnia or other sleep
(02:27:08)
problems okay the next thing I want
(02:27:10)
parents to understand is to avoid
(02:27:13)
treatments that we know don't work or
(02:27:15)
that have a very low probability of
(02:27:18)
succeeding by the way if these don't
(02:27:20)
correspond to your manual exactly I
(02:27:23)
changed a few of them yesterday okay I
(02:27:26)
try to keep my slides as up to dat as
(02:27:27)
possible or when I go through them and I
(02:27:29)
don't like the teaching the the flow I
(02:27:31)
may change them a little bit so if
(02:27:32)
you're not seeing exactly what I have my
(02:27:34)
apologies but you've got 99% of what
(02:27:37)
I've been talking
(02:27:38)
about these are the things to avoid all
(02:27:41)
right why because either they're so
(02:27:43)
silly we're never going to look at them
(02:27:44)
right or they've already been looked at
(02:27:47)
and they don't work right taking
(02:27:49)
something out of the DI
(02:27:51)
benefits about one out of every 20 ADHD
(02:27:54)
children we're talking here about
(02:27:55)
colorings flavorings and preservatives
(02:27:58)
do some ADHD children react adversely to
(02:28:01)
these yes do most no it's mainly
(02:28:05)
children five and younger and it's about
(02:28:08)
1 in
(02:28:09)
20 so do we recommend elimination diets
(02:28:13)
as a blanket Panacea treatment for ADHD
(02:28:15)
as was done by fine gold and others no
(02:28:18)
might it benefit the occasional rare
(02:28:20)
child
(02:28:21)
yes next there is nothing you can put in
(02:28:24)
the diet that treats this disorder so
(02:28:27)
whether it's antioxidants whether it's
(02:28:29)
the fish oils whether it's Mega vitamins
(02:28:32)
we have yet to find anything that
(02:28:34)
benefits ADHD the fish oil study the
(02:28:37)
best one was published just a month ago
(02:28:39)
by the Swedish uh research team in
(02:28:41)
gothenberg best trial I've ever seen and
(02:28:44)
they reported very sobering negative
(02:28:46)
results only 25% of the kids responded
(02:28:49)
it was mainly the inattentive
(02:28:51)
kids the degree of response was very
(02:28:53)
slight so even they recommended against
(02:28:56)
it any positive reports you've heard
(02:28:58)
were not from well-controlled
(02:29:01)
studies I'll get to my questions in just
(02:29:03)
a moment yeah
(02:29:12)
sure thanks Heidi I'm sorry about
(02:29:14)
that
(02:29:18)
yeah next fastest growing tree in the US
(02:29:21)
school system right now for ADHD is
(02:29:23)
sensory integration training this is a
(02:29:25)
special set of exercises done by some
(02:29:26)
occupational therapists who have gotten
(02:29:28)
additional training in the SI techniques
(02:29:31)
and in assessing for sensory integration
(02:29:33)
problems this has been resoundingly
(02:29:36)
disproved so this is an area that has
(02:29:38)
been studied but you'd never know it by
(02:29:40)
the number of people being exposed to
(02:29:42)
this treatment it is proven to be of no
(02:29:43)
benefit for LDS or ADHD even their own
(02:29:47)
journal published a metaanalysis that
(02:29:49)
showed that and yet we go on seeing
(02:29:51)
sensory integration being offered as a
(02:29:54)
special set of exercises to treat
(02:29:56)
ADHD why would massaging the head do
(02:29:59)
anything for ADHD yet chiropractors do
(02:30:03)
engage in what is called skull massage
(02:30:05)
or neurologic organization training
(02:30:07)
claiming that they can successfully
(02:30:09)
treat ADHD through skull massage it's a
(02:30:12)
silly idea we won't go there play
(02:30:15)
therapy has been tested it does not work
(02:30:17)
for ADHD because ADHD does not arise
(02:30:19)
from environment mental stress so why
(02:30:22)
would helping children cope with stress
(02:30:24)
solve this problem that does not mean it
(02:30:26)
may not benefit anxious children PTSD
(02:30:28)
children or children with depression but
(02:30:31)
it doesn't benefit ADHD children for
(02:30:33)
their
(02:30:34)
ADHD self-control training I mentioned
(02:30:37)
earlier this is talking to
(02:30:38)
yourself so teaching children to talk
(02:30:41)
out loud as they perform a task we had
(02:30:43)
Great Hopes for this and it failed but
(02:30:46)
the diamond in that dung Heap is that we
(02:30:48)
found that it was age related the
(02:30:50)
younger you are the less likely it works
(02:30:52)
but by late adolescence to adulthood it
(02:30:55)
does work but only if you're on
(02:30:57)
medication it is a supplement to
(02:31:00)
medication not a form or alternative to
(02:31:03)
medication there are several books on
(02:31:04)
the market now that were developed by
(02:31:06)
these researchers one is Steve saffron
(02:31:08)
at Harvard Med School he now has a
(02:31:10)
cognitive therapy manual for adult ADHD
(02:31:13)
and the other is by Russell Ramsey at P
(02:31:15)
or University of Pennsylvania you could
(02:31:17)
find both of these at Amazon or at the
(02:31:20)
add warehouse.com if you're into adult
(02:31:23)
ADHD treatment social skills training
(02:31:25)
should not be done for the average ADHD
(02:31:28)
child unless it's being done at school
(02:31:30)
or with the peer group with whom he is
(02:31:32)
having trouble and then it should be
(02:31:34)
mostly practice queuing and rewarding
(02:31:37)
the use of the skill and a lot less time
(02:31:41)
spent in training the skill what's the
(02:31:44)
proportion 8020 80% altering the point
(02:31:47)
of performance 20% training and the
(02:31:49)
skill and if you follow that balance and
(02:31:51)
you do it out there where it matters it
(02:31:53)
might have a chance if you do it in a
(02:31:55)
clinic with the kids he'll never see
(02:31:57)
again the rest of his life it doesn't
(02:31:59)
work next to the last idea for you right
(02:32:03)
25 to 35% of the parents of ADHD
(02:32:06)
children are ADHD themselves it used to
(02:32:09)
be people didn't care they didn't ask
(02:32:11)
they didn't want to know or they didn't
(02:32:13)
think it mattered now we know it matters
(02:32:16)
first of all it matters that your own
(02:32:18)
ADHD needs to get treated because we've
(02:32:20)
studied now the impact of ADHD on
(02:32:23)
parents whether they have ADHD children
(02:32:25)
or not we now have a series of studies
(02:32:27)
particularly the work of Charlotte
(02:32:29)
Johnston at University of British
(02:32:30)
Columbia and Andrea cronis at University
(02:32:32)
of Maryland who have now studied parents
(02:32:34)
who have this disorder and what it does
(02:32:36)
to their parenting and you can see the
(02:32:38)
obvious things here greater
(02:32:40)
impulsiveness higher rates of expressed
(02:32:41)
emotion greater rates of
(02:32:44)
disciplining lower rates of Parental
(02:32:47)
monitoring of children all of which
(02:32:49)
increase inrees the risk for
(02:32:51)
oppositional disorder in the child so
(02:32:54)
the parent ADHD needs to be detected and
(02:32:57)
managed not just the child's ADHD and
(02:32:59)
also more recently it is the best
(02:33:01)
predictor of who fails in behavioral
(02:33:04)
parent training is the parent themselves
(02:33:06)
has the same disorder my last admonition
(02:33:09)
to you is one that Leo Balia wrote about
(02:33:11)
30 years ago in his book for families of
(02:33:14)
and autistic children in this
(02:33:17)
book Balia said one of the most
(02:33:18)
important things a family of disabled
(02:33:20)
youngster can do is to practice
(02:33:23)
forgiveness and he meant by this four
(02:33:26)
things you better get good at forgiving
(02:33:29)
yourself for your mistakes you will make
(02:33:31)
them we all make them even raising
(02:33:33)
normal children you will make more of
(02:33:34)
them because ADHD children know just how
(02:33:37)
to push your buttons to get you to do
(02:33:40)
things you
(02:33:41)
regret so you better get good at
(02:33:44)
forgiving yourself those mistakes and if
(02:33:46)
Judy Harris is correct you don't matter
(02:33:48)
anyway
(02:33:50)
you're not as important as you thought
(02:33:51)
you were so relax a little bit it's okay
(02:33:55)
you know what really matters as pascala
(02:33:57)
said do you try to get it right the next
(02:33:59)
time it's not did you make the mistake
(02:34:02)
it's what are you going to do about it
(02:34:03)
tomorrow to make sure that it doesn't
(02:34:05)
happen again that's a very important
(02:34:07)
idea one of the things that I think um
(02:34:11)
will be very helpful in helping you to
(02:34:13)
do this uh is to step back to that
(02:34:16)
principle about being a Shepherd you're
(02:34:19)
not an engineer
(02:34:21)
so it matters what you do but it doesn't
(02:34:22)
matter that much what you do and I find
(02:34:25)
it's better if you have the shepherd's
(02:34:26)
view because you start to look at your
(02:34:28)
children in a very different light as
(02:34:31)
things to be enjoyed and celebrated and
(02:34:33)
cherished for their uniqueness as
(02:34:36)
opposed to being mounds of clay that you
(02:34:39)
can sculpt into whatever you choose to
(02:34:41)
do you just don't have that kind of
(02:34:43)
power the second area of forgiveness is
(02:34:46)
that of your child this is harder okay
(02:34:49)
this is harder because resentment can
(02:34:50)
build up the mistakes are there the
(02:34:52)
misbehavior is there you are being given
(02:34:54)
misbehavior
(02:34:56)
247 that you have to deal with you have
(02:34:58)
had to step up to the plate and become
(02:35:00)
your child's frontal Loaves and it's not
(02:35:03)
easy it is
(02:35:05)
exhausting and there's a tendency among
(02:35:07)
some parents to allow a certain amount
(02:35:09)
of resentfulness to creep into this a
(02:35:11)
wish that you had a different child a
(02:35:13)
better child a normal child and boy that
(02:35:16)
is just one step away from justifying
(02:35:18)
child abuse the idea that your child may
(02:35:21)
be doing this intentionally is one of
(02:35:23)
the sources of
(02:35:25)
resentfulness so you better get good if
(02:35:27)
for giving these kids their mistakes
(02:35:28)
they make a lot of them right so here's
(02:35:30)
a couple of suggestions that parents
(02:35:32)
have told me about that work for them
(02:35:33)
and I love these ideas and I put them in
(02:35:35)
my parents book number one at the end of
(02:35:38)
the day after dinner when you're having
(02:35:41)
your coffee or your CAC or whatever I
(02:35:44)
want you to take out a sheet of paper I
(02:35:46)
want you to write down all the problems
(02:35:49)
you had with this kid did today write
(02:35:51)
them all down every one of them all
(02:35:52)
right exercise your demons get them down
(02:35:56)
on the paper then I want you to go to
(02:35:58)
the sink take a match and light them I
(02:36:00)
want you to burn them all up there they
(02:36:01)
go gone you have now performed the
(02:36:04)
ritual exorcism the demons are gone the
(02:36:07)
day is over Let It Go all right the
(02:36:12)
second thing one of the parents taught
(02:36:13)
me that she found was so useful is after
(02:36:16)
your child has fallen asleep go upstairs
(02:36:20)
sit on the floor in a yoga position you
(02:36:24)
know and watch your child
(02:36:27)
sleep just breathe in and out and watch
(02:36:31)
there is nothing more innocent than
(02:36:33)
watching a young child sleep and if that
(02:36:37)
doesn't renew your batteries and restore
(02:36:39)
your balance to your view of your child
(02:36:41)
I'm not sure what will maybe a glass of
(02:36:44)
wine while you're watching the
(02:36:47)
child but whatever it takes to let let
(02:36:50)
these go and to try to get better
(02:36:53)
tomorrow that's what really matters not
(02:36:55)
the mistakes you make and the same
(02:36:57)
applies to your partner your spouse
(02:36:59)
don't get all upset because they're not
(02:37:00)
doing it quite the way you want it done
(02:37:03)
or vice versa and then of course the
(02:37:05)
last one is the one you're all here for
(02:37:07)
I hope as well and that is to learn more
(02:37:10)
about ADHD but in learning you realize
(02:37:12)
that the public doesn't understand this
(02:37:13)
disorder the way we do that they are
(02:37:16)
ignorant of this disorder and its causes
(02:37:19)
so you you better get good at forgiving
(02:37:21)
other people who glare at you in Walmart
(02:37:24)
because your child is a handful who
(02:37:27)
stare at you in the Outback restaurant
(02:37:30)
who look at you as if this is your fault
(02:37:33)
my sister-in-law has an ADHD son this is
(02:37:36)
my nephew
(02:37:38)
Dan one time she was in Target and an
(02:37:41)
older woman came over to her and said
(02:37:44)
why don't you control your child you
(02:37:45)
know this is all your fault if young
(02:37:47)
parents like you would just take this
(02:37:49)
bull by the horn and discipline these
(02:37:50)
kids for we wouldn't be having these
(02:37:52)
trouble and she followed my
(02:37:53)
sister-in-law out the car out to the to
(02:37:56)
the car at the car stood there yelling
(02:37:58)
at her while she locked her door and she
(02:38:01)
was in tears over this now that's an
(02:38:03)
extreme example but don't tell me this
(02:38:05)
can't happen most of you have had these
(02:38:07)
looks thrown at you about your child and
(02:38:11)
sometimes it goes up a notch so you
(02:38:13)
better get a thick skin about the public
(02:38:16)
that doesn't understand this disorder
(02:38:19)
now there's a cognitive therapy
(02:38:20)
technique that you can use while you're
(02:38:22)
looking at these people you can be
(02:38:24)
saying in your mind what's it to you
(02:38:26)
pork
(02:38:28)
face but I don't want you to say it out
(02:38:32)
loud right this is just cognitive
(02:38:36)
therapy you're an idiot you don't know
(02:38:38)
what you're talking about if you had one
(02:38:40)
of these kids walk a mile in my shoes
(02:38:43)
but just shut up drive on get on with
(02:38:45)
your life but you better get good at
(02:38:47)
forgiving the public their
(02:38:48)
misunderstanding cuz boy do they
(02:38:50)
misunderstand this disorder I'll hang
(02:38:53)
around for a few questions but I hope
(02:38:55)
you enjoyed the 30 things families need
(02:38:58)
to understand about
(02:39:00)
a thank you
(02:39:05)
[Applause]
(02:39:23)
does the 30% rule apply to UNM
(02:39:25)
medication no because in 55 to 65% of
(02:39:29)
the cases of children the medication
(02:39:31)
will normalize them so that's that's
(02:39:34)
over a half and in some cases 2/3 the
(02:39:37)
30% is gone only when the medication is
(02:39:40)
active so at the end of the day here it
(02:39:43)
comes and by 8:00 at night you're back
(02:39:46)
to 30% again so just keep in mind that
(02:39:49)
it can normalize some children in the
(02:39:51)
remaining 30% the Gap is closed but not
(02:39:55)
completely there is Improvement but not
(02:39:57)
normalization other things will have to
(02:39:59)
be done to help with that Gap and then
(02:40:03)
there's about 10 to 15% of the kids who
(02:40:05)
don't respond to any particular agent
(02:40:08)
and in that case you're just going to
(02:40:10)
have to deal with the full 30% and
(02:40:12)
accommodate it as best you can thank you
(02:40:14)
so good question
(02:40:29)
well I don't know that there's one best
(02:40:30)
way because let's face it there are some
(02:40:32)
neighbors or some parents of other
(02:40:34)
friends who are going to respond to
(02:40:36)
anything and they don't want your kid
(02:40:38)
around and it's best that your child
(02:40:40)
find another set of friends or stay away
(02:40:42)
from that home they don't need to be
(02:40:43)
here in that stuff but most parents are
(02:40:45)
fairly reasonable people and I think if
(02:40:47)
you went to them if you downloaded a
(02:40:49)
back sheet on ADHD from my website or
(02:40:52)
the Chad website uh and you just took it
(02:40:54)
to them this sort of two to three page
(02:40:57)
description or you called them and said
(02:40:58)
you know I've been meaning to come by or
(02:41:00)
have you over for a coffee or as part of
(02:41:02)
this little social coffee clutch or
(02:41:04)
whatever you introduce this information
(02:41:06)
about your child about their diagnosis
(02:41:08)
about what it is and the various things
(02:41:10)
that you you all are trying to do to
(02:41:11)
contend with it I think you you might
(02:41:13)
find these people being more
(02:41:15)
compassionate than they ordinarily would
(02:41:16)
they're probably laboring under a lot of
(02:41:18)
misimpressions that the public has
(02:41:20)
anyway that this your child could be
(02:41:22)
better this is your fault it's a result
(02:41:24)
of parenting and we sort of need to
(02:41:26)
disabuse them of those ideas but I I
(02:41:29)
like the honesty as the best policy
(02:41:31)
approach to begin with now obviously if
(02:41:32)
in the middle of this conversation it
(02:41:34)
becomes very clear that these parents
(02:41:36)
don't care don't understand and don't
(02:41:38)
want to then you you should not be
(02:41:40)
allowing your child to play at their
(02:41:41)
home or under their supervision um feel
(02:41:44)
free to invite their child over to your
(02:41:46)
house if they'll allow it but uh I still
(02:41:48)
think inform forming the public uh we've
(02:41:51)
had some teenagers carry around a card
(02:41:53)
about ADHD in their wallet so that they
(02:41:55)
can show it to people who are not
(02:41:57)
familiar with ADHD a coach or a
(02:41:59)
policeman that pulls him over for
(02:42:01)
speeding or you know something like that
(02:42:04)
but uh very much like we got the idea
(02:42:06)
from the Tourette Syndrome Foundation
(02:42:08)
which publishes small cards that are
(02:42:09)
information that allow Tourette's people
(02:42:12)
to share the information without
(02:42:13)
necessarily having to explain it all
(02:42:15)
themselves but here's a sheet from a
(02:42:18)
reputable Source like Chad or my website
(02:42:21)
that that they can learn from the most
(02:42:22)
you can do is to try to persuade them
(02:42:24)
inform them maybe change their mind and
(02:42:26)
then the rest is shopping for more
(02:42:27)
reasonable friends and parents of
(02:42:29)
friends if you can now some people ask
(02:42:32)
well well my child doesn't have an awful
(02:42:34)
lot of friends what can I do to try to
(02:42:36)
improve that make your house the best
(02:42:38)
place to play on the
(02:42:40)
street it's bribery but I don't care how
(02:42:43)
you do it yeah you need to have the best
(02:42:45)
toys in the yard you need to have the
(02:42:46)
best games in the house you need to be
(02:42:48)
somebody who feeds all visitors so that
(02:42:51)
when everybody when anybody shows up man
(02:42:53)
there's a fudge sickle in your hand and
(02:42:55)
an Oreo and a glass of milk and here's
(02:42:57)
the Wii system and I mean you are just
(02:43:00)
going to create this place where they
(02:43:02)
love being there whether your son is
(02:43:03)
there or not right uh and hopefully some
(02:43:07)
of these friendships will stick or take
(02:43:09)
or they'll be a little more forgiving of
(02:43:11)
your child's immaturities because you're
(02:43:13)
such a great place to be um however you
(02:43:16)
can arrange this environment you can't
(02:43:18)
make other children like your child that
(02:43:21)
is not possible to do you can only make
(02:43:24)
them more likeable or make the
(02:43:27)
environment in which your child exists
(02:43:29)
more likable and hopefully some of that
(02:43:32)
sticks so approach it that way but you
(02:43:34)
can't make another child want to play
(02:43:36)
with your child it's just not going to
(02:43:37)
happen those children make their own
(02:43:44)
choices there are a number of treatments
(02:43:47)
on the market right now that are based
(02:43:49)
on these neuros cych theories of ADHD as
(02:43:52)
an executive disorder particularly that
(02:43:54)
involves working memory uh toal kingberg
(02:43:58)
is the developer of cogmed it's a he's a
(02:44:00)
Swedish scientist uh cogmed is is
(02:44:03)
working memory training it's practicing
(02:44:05)
digits band forward and backward and
(02:44:07)
spatial memory forward and backward for
(02:44:09)
about 45 minutes a day with your child
(02:44:11)
you do need to reward them because this
(02:44:12)
gets boring to tears after the first day
(02:44:14)
or two uh so you have to have a token
(02:44:16)
system and a reward program in place
(02:44:18)
program cost several thousand
(02:44:20)
now I have I have visited Sweden and his
(02:44:24)
lab I've gone over their data and it
(02:44:26)
does look like this produces a temporary
(02:44:29)
Improvement in working memory and that
(02:44:31)
result in a temporary decrease in ADHD
(02:44:34)
symptoms but even kingberg has shown
(02:44:36)
that with three months of training or up
(02:44:39)
to six months of training the effect
(02:44:41)
might last maybe three months and then
(02:44:44)
you have to start the retraining again
(02:44:45)
so this is he Likens it I think very
(02:44:48)
aptly to to an athlete like a
(02:44:50)
weightlifter trying to train muscle mass
(02:44:53)
this isn't anything willful you're just
(02:44:54)
trying to expand the capacity of the
(02:44:56)
brain for working memory and just like
(02:44:58)
an athlete who exercises I can build up
(02:45:00)
my biceps but if I stop exercising for a
(02:45:03)
month guess what's going to happen my
(02:45:05)
bicep is going to atrophy now because
(02:45:07)
it's not being exercised as much and the
(02:45:09)
same is true with these
(02:45:10)
neuropsychological training programs
(02:45:12)
that we have seen so far now kingberg
(02:45:15)
gets royalties from the company and we
(02:45:18)
would like to see his research
(02:45:19)
replicated by someone who does not have
(02:45:21)
a financial stake in the success of the
(02:45:24)
company so it is being tested at five
(02:45:26)
universities in the US I know of at
(02:45:28)
least one here in Canada as well when
(02:45:30)
these studies are over we're going to
(02:45:32)
have an idea about whether his findings
(02:45:33)
could be replicated but even if they are
(02:45:36)
replicated let's not forget what he
(02:45:38)
found this is a temporary exercising
(02:45:41)
program that has to be reinstituted
(02:45:42)
several times a year to sustain the
(02:45:45)
gains now let me tell you something else
(02:45:48)
if it turns out that this works why
(02:45:51)
would you spend several thousand doll
(02:45:53)
when you can buy a Nintendo DSS and the
(02:45:55)
Brain Age software which does both of
(02:45:58)
these things as well as at least six
(02:46:00)
other frontal lobe executive function
(02:46:02)
tasks it's just as much fun if not more
(02:46:05)
so it's on10th the cost so I would
(02:46:09)
direct you to Nintendo before I would
(02:46:11)
say send you to cogmed and if you don't
(02:46:14)
want to invest the couple hundred bucks
(02:46:15)
that DSS cost with the software get
(02:46:18)
scientific ific American mind this is
(02:46:21)
the Popular Science magazine Scientific
(02:46:23)
American they also published one called
(02:46:26)
Scientific American mind the last issue
(02:46:29)
of Mind was a review of all internet
(02:46:32)
sites that have executive function
(02:46:34)
training programs on them where you can
(02:46:36)
go some of them are free most of them
(02:46:38)
have a monthly fee that you can sign on
(02:46:40)
for and there's the software there's the
(02:46:43)
games there's tracking your successes
(02:46:45)
and failures all the things that
(02:46:47)
Nintendo and cogmet are doing can be
(02:46:49)
done through these websites without
(02:46:50)
buying the equipment usually for like N9
(02:46:52)
or 10 bucks a month some are more some
(02:46:54)
are less some are more interesting some
(02:46:56)
are less interesting but there's a
(02:46:58)
review of all of these brain training
(02:47:01)
websites in that magazine and it's very
(02:47:04)
good by the way Nintendo comes out
(02:47:06)
looking really good because it's the
(02:47:07)
only portable system you can take
(02:47:09)
anywhere and practice any time even if
(02:47:11)
you're waiting in a car for little
(02:47:12)
league to start you know so um look
(02:47:15)
around cogmet isn't the only thing out
(02:47:17)
there but let's wait for the research to
(02:47:19)
come out before we know whether this is
(02:47:20)
really going to turn out to be a A
(02:47:23)
coping tool and that's all it is it is
(02:47:25)
not a cure not by any means that was
(02:47:27)
probably more information than you ever
(02:47:29)
wanted to hear right
(02:47:45)
okay all right here is the relationship
(02:47:48)
right the relationship between ADHD and
(02:47:50)
bipolar is a one-way Street ADHD
(02:47:53)
children carry no elevated risk for
(02:47:55)
bipolar disorder over that of the
(02:47:56)
general population no longitudinal
(02:47:59)
Studies have found that to be the case
(02:48:00)
my own included not the Canadian studies
(02:48:02)
not the New York studies not the Iowa
(02:48:03)
not the Swedish not the Australian risk
(02:48:05)
is 2 to 4% which is the population rate
(02:48:08)
so if a child starts out ADHD that's
(02:48:11)
probably what they're going to stay
(02:48:13)
bolar becomes a very remote
(02:48:15)
diagnosis however if there is bip polar
(02:48:19)
disorder in the family the risk goes up
(02:48:22)
eight times now the real relationship is
(02:48:26)
from bipolar to
(02:48:28)
ADHD if a child has bipolar disorder
(02:48:32)
already and it started in childhood the
(02:48:36)
risk is 80 to 97% that they will have
(02:48:38)
ADHD along with it and that is why the
(02:48:41)
confusion people saw that so many
(02:48:43)
bipolar children had ADHD they made the
(02:48:46)
leap that the opposite had to be true
(02:48:48)
that ADH HD was a big risk for bipolar
(02:48:51)
and it turned out to be no risk for
(02:48:52)
bipolar disorder unless the family
(02:48:54)
history of bipolar illness is there and
(02:48:57)
then the genetic risk for bipolar
(02:48:58)
disorder obviously are what mediate that
(02:49:00)
high risk so bipolar disorder only if it
(02:49:04)
starts in childhood carries a very high
(02:49:06)
risk for ADHD along with it and ADHD is
(02:49:09)
usually the first disorder to
(02:49:11)
start if the bipolar starts in
(02:49:14)
adolescence the risk is 40 to 45% that
(02:49:16)
ADHD is with it if it starts in
(02:49:18)
adulthood which is is the more typical
(02:49:19)
form of bipolar disorder the risk is
(02:49:21)
only 20 to 25% so notice it's the early
(02:49:24)
onset bipolar that brings the risk of
(02:49:27)
ADHD with it not the other way around
(02:49:29)
now if there's bipolar there and it
(02:49:31)
started in childhood it is one of the
(02:49:33)
worst psychiatric disorders a child can
(02:49:35)
have barring infantile autism or
(02:49:38)
schizophrenia very difficult to manage
(02:49:40)
it requires multiple medications to try
(02:49:42)
to deal with it there was obviously an
(02:49:44)
increased risk of uh not just
(02:49:46)
destructiveness but violent Behavior
(02:49:48)
particularly in males
(02:49:49)
uh there is periodic hospitalization for
(02:49:51)
safety as well as for uh reengineering
(02:49:55)
the psychopharmacology that is testing
(02:49:56)
the drugs many of the drugs used with
(02:49:59)
bipolar disorder have far more serious
(02:50:01)
side effects than the ADHD drugs do and
(02:50:03)
so children are often hospitalized
(02:50:05)
partly to monitor the side effects as
(02:50:07)
they're tit treating them the bipolar
(02:50:09)
child has a massive increase in risk for
(02:50:12)
suicide and drug abuse as they enter
(02:50:15)
adolescence uh so this is not a fun
(02:50:18)
disorder but it's 2 to 3% roughly of
(02:50:21)
children have the bipolar disorder and
(02:50:23)
it is severe and it is usually lifelong
(02:50:26)
and it often requires poly Pharmacy and
(02:50:28)
periodic hospitalization so the news
(02:50:30)
isn't good um but at least we can say
(02:50:33)
ADHD is not a cause of bipolar disorder
(02:50:36)
most ADHD children are never at risk for
(02:50:38)
it but if there's a family genetic link
(02:50:40)
to bipolar then that young child with
(02:50:43)
ADHD may also carry that link and that
(02:50:46)
risk
(02:50:55)
okay there are more than 400 studies of
(02:50:58)
the stimulants uh there are additional
(02:51:00)
studies of the other drugs like
(02:51:02)
atomoxetine they're all Placebo
(02:51:03)
controlled the placebo rate in most
(02:51:06)
studies is between 10 and
(02:51:08)
35% the rate of responders to the active
(02:51:11)
medication is between 55 and 92%
(02:51:14)
averaging to about 75% so it's twice the
(02:51:17)
placebo rate so at this point point we
(02:51:19)
can be assured from these randomized
(02:51:21)
Placebo controlled studies that the
(02:51:23)
medication has a real effect not just an
(02:51:26)
effect of psychological
(02:51:28)
suggestibility uh as the placebo effect
(02:51:30)
might suggest so all I can tell you is
(02:51:32)
those Studies have been done they've
(02:51:33)
been done repeatedly and we can be
(02:51:35)
assured this is not a placebo effect it
(02:51:37)
doesn't mean there isn't a little bit of
(02:51:38)
a placebo effect but most of the effect
(02:51:40)
is clearly that of an active agent
