Thinking of ADHD as a deficit of Executive Function (EF) offers a wealth of treatment possibilities. For clinicians, adults with ADHD, and parents of children with ADHD, this executive function conceptualization opens up a new way to organize thinking around deficits and strengths, and points the way to generating effective treatment plans.
I recently read an excellent article from Dr. Thomas E. Brown of the Yale Clinic for Attention and Related Disorders, titled ADD/ADHD and Impaired Executive Function in Clinical Practice. In it, Brown defines ADHD as “a cognitive disorder, a developmental impairment of executive functions (EFs), the self-management system of the brain.” By stepping away from the behavioral aspects of ADHD and moving toward this cognitive understanding, treatment planning can be readily tailored to compensate for specific missing skills and abilities. I frequently direct my clients to create structure and systems which will shore up the weaker areas, allowing them to improve their performance.
In Brown’s article, he defines six areas of Executive Function Deficit. The first, called activation, includes activities required in beginning to work. Clearly, this deficit is familiar to anyone struggling with procrastination. Second, Brown defines focus, the difficulty in actually paying attention to the work at hand. Third would be effort, especially as needed to complete longer tasks. Fourth is emotional regulation. (Emotional regulation is not mentioned specifically in the symptom list in the DSM-IV or 5, but the inclusion of it in the DSM-5 was articulately argued for by Russ Barkley in his keynote to the CHADD conference.) Brown mentions memory as the fifth executive function, especially memory for more recent events, and problems in holding information. The sixth and final executive function is action, including impulsivity, pacing and taking in feedback from others.
Russ Barkley offers both the Barkley Deficits in Executive Functioning Scale (BDEFS for Adults) and the Barkley Deficits in Executive Functioning Scale--Children and Adolescents (BDEFS-CA), which allow clinicians to evaluate client’s executive functioning in their daily life. The executive functions in the BDEFS are similar to Brown's, broken down to time management, organization and problem solving, self-restraint, self-motivation, and self-regulation of emotions. Because the BDEFS is a validated measure, results of the test can indicate exactly where individuals are struggling and what can be done to improve performance.
For some clients, medication alone can have a huge impact, for others, therapy such as Cognitive Behavioral Therapy (CBT) can address problem areas. Many clients can benefit from a combination of medication and therapy. I've found this EF conceptualization to be especially effective in treatment planning for my clients.
Late, Lost, and Unprepared: A Parents' Guide to Helping Children with Executive Functioning ,by Joyce Cooper-Kahn, Ph. D. And Laurie Dietzel, Ph. D. is, yes, another book on helping kids develop executive function. But that’s not necessarily a bad thing. Different books (several of which I’ve reviewed here) on the topic offer similar ideas, but the details vary and one book may work better for your child than another. The first part of Late Lost, and Unprepared thoroughly explains executive function, breaks executive function down into a list of specific skills, and discusses the developmental aspects of executive function. If this is the first book you’ve read about helping your child, it’s certainly worth the time to read this carefully.
The second half of the book, “What You Can Do About It”, is of value even to those who have read a number of other books on the topic of executive function. This book’s strength is in breaking issues down methodically. As a former engineer, I know that the best way to get to a solution is to deal with a series of simple issues, rather than one overwhelming problem. This book helpfully lists very concrete, specific issues for each category of executive functioning. For example, one chapter about impulse control addresses specific problems like interrupting others, hitting others, and running off in stores.
A strength of this approach is that the authors present both short term and long term solutions. This is what every parent needs to remember, that executive skills improve with growth and maturity. While short term solutions stop disasters from happening, longer term solutions are what will be truly valuable to maturing individuals.
Another strength of the book is that it discusses how parents can advocate for their child. It’s ideal for every child if all the people dealing with him can be working toward the same solutions. This book makes that idea straightforward and easy to figure out.
Marriage always involves compromise and adjusting for differences, and that’s even more true when one partner has a diagnosis, like autism, Asperger’s, or ADHD. In my therapy practice I work with many of these mixed couples, where it’s not just two different personalities, but also two different ways of experiencing and dealing with the world. These differences can bring a refreshing sense of novelty, perspective, and balance to a relationship, but they can also result in conflict, disappointment, and disconnect. Fortunately, understanding those differences between partners can be the first step in bringing a troubled relationship into one that’s supportive and satisfying for both.
Gina’s Pera’s Is It You, Me, or Adult ADD? was written as a support group in book form, focused on the partners of adults with ADD or ADHD, and Pera uses the voices and examples of support group members throughout. But, don’t be fooled by the support group theme. This book is an extensive and well researched resource, covering not just anecdotal examples but also thoroughly detailing treatment options, historical background and professional discussions of ADHD. I always appreciate writing that’s easy to read while still being informative and professionally referenced. This book will serve as a useful long term reference as well as a book to read through.
I read some reviews criticizing Is It You, Me, or Adult ADD? for siding with the non-ADHD partner and blaming all the marital problems on ADHD and the ADHD partner. Although I think this can be a fair criticism in general, the book really isn’t directed at those couples where ADHD is bringing creativity and spontaneity to the marriage. People attend support groups because they need support with problems and they pick up a book like this because there’s something wrong in their relationship. It’s reasonable to address the problems the diagnosis brings in these cases.
Is It You, Me, or Adult ADD? is an excellent resource for couples dealing with ADHD and I recommend it highly.
Ed Rev 2011 will be held on Saturday, April 16, 2011 at AT&T Park. Ed Rev 2011 is "a day of inspiration and resources for students with learning and attention difficulties, and their parents and educators." The day includes speakers, activities, and an art contest. Whether or not you can attend, it's worthwhile to check out the excellent list of exhibitors and resources. Check out the brochure.
Kids with special needs like ADHD, ASDs and learning differences can frequently benefit from specialized tutoring and academic programs. But there are so many options, it’s difficult to choose what’s appropriate. And for adults, it can feel too late to get the help they need.
Today, I’m interviewing Theresa Rezentes, of Dyslexia Connections. Theresa is certified in both Slingerland Reading methods and Lindamood-Bell methods. She works in schools as well as individual students in Alameda and Western Contra Costa County.
P. R. What are the signs that a child could benefit from working with a reading program?
T. R. As a reading therapist, I tutor kids who read below grade level despite an average to above average intelligence and who exhibit signs of letter direction confusion (b and d or b and p are most common), or who transpose letters (change their order) as exhibited in writing or oral reading. Also, the child avoids reading for pleasure despite many encouragements.
P. R. What are these different reading programs?
T. R. As these children are three dimensional, hands-on learners, many need to write letters and words in the air with their whole arm to give them meaning. The above confusions can be so distracting that only by writing the letters in the air while saying them and pronouncing them immediately following give them the scaffolding needed to make sense of words and reading. This physical relationship is what is needed to permanently bypass the confusions that many children see if they have trouble reading. Also, both the Slingerland and Lindamood-Bell Methods focus on auditory processing weaknesses which the majority (80%) of these students possess.
P. R. Can this be helpful for adults?
T. R. Yes, it is but will take longer to make progress. I compare it to learning Spanish as an adult vs. as a child. The reason is that the neuropathways are more solidified with adults compared to children. Therefore, the letter confusions are more permanent and will take longer to correct. However, with therapy of three or more hours a week, progress can be made. The bottom line is that it takes a true commitment of the adult.
P. R. How does this differ from what's taught in schools?
T. R. For years, the Slingerland Institute had trained teachers using this method with hopes it would reach the schools. Unfortunately, because most principals are not aware of these methods they are not supported by administrators and many of these children end up in Special Education with an IEP. The Slingerland Method is available in many Catholic Schools in the Oakland Diocese. It has widespread support of the diocese and I treat children who attend Catholic schools.
The Lindamood Bell method is available in only two schools in Oakland. The Susan Barton Method is available in the Pleasanton USD and San Ramon USD. Both Lindamood Bell and Susan Barton require one on one tutoring and most schools cannot afford to have one employee work with one student several hours a week. It is really through parental efforts and pressure that enable these methods to be available in the public schools, typically through a lawsuit settlement, or through private tutors certified in these areas. I am certified in both Lindamood-Bell and Slingerland.
P. R. Thanks, Theresa.
For those interested in learning more, please visit Dyslexia Connections.
Book Review: Out of the Fog, Treatment Options and Coping Strategies for Adult Attention Deficit Disorder
So much of what’s written about ADHD is aimed at parents. But the disorder doesn’t just disappear when these kids grow up. Based on information published on Russell Barkley’s website, 65 to 80% of children with the disorder continue to have impairments as adults. This can range from school, employment, and interpersonal issues to conditions as severe as mental illness, substance abuse and legal problems.
I’ve published several good reviews on coping with ADHD in this blog. Smart But Scattered and Late, Lost and Unprepared are two favorites. Although they tend to focus on children’s issues, many of the technique can be adapted to adults.
But it’s always best to be able to find something uniquely adapted to your own situation, which is why I was to pleased to find Out of the Fog, Treatment Options and Coping Strategies for Adult Attention Deficit Disorder, by Kevin R, Murphy, Ph.D. and Suzanne LeVert. Dr. Murphy was a researcher at the Adult ADHD Clinic at the University of Massachusetts, and is now in private practice. Out of the Fog is a book that really attempts to do it all: explain the condition of Adult ADHD, discuss treatments and strategies, and cover practical aspects such as organization and communication. With a lesser author, this approach might be too much at cover, but Murphy is so knowledgeable, he’s got good advice for all these varied aspects. Because the book was written in 1995, it doesn’t use some of the newer terminology, such as “Executive Function”, and the specific medication information is showing its age. In general though, the information in this practical guide is still useful and timely.
School started a few weeks ago, the novelty is wearing off, and routines are setting in. Although it’s tempting to just settle in and let things run their course, now is really the perfect time to look closely at what’s going well and to uncover those little problems that might get bigger. This is true for all students, from kindergarteners to university students. Little, developing problems are easier to solve and there’s still plenty of time to make up for any lower grades. Habits haven’t set in too much yet and it’s easy to create new routines.
First, it’s important to think about what went well last year, and what you’d like to change this year. Did missing assignments snowball into low grades? Did you get overinvolved as a parent, not allowing your child to develop independent skills? Did you forget to factor in time for social connections with other students?
Second, look closely at how that aspect is going this year. Are you just starting to see one or two missing assignments? Are you jumping in a bit to nag, (help) your child? Are you ducking into the library at lunchtime?
Third, look for those tiny changes you can make to improve the situation. The best results often come from rules or systems. Can you start checking the school website every evening before going to bed, and make sure you’ve completed, and packed up, all your assignments? Can you set up a check list for your child, and then let her be responsible for her own work? Can you promise yourself that just once a week, you’ll take the risk and eat lunch with someone else?
Remember, the earlier in the year you try making changes, the bigger the impact of those changes.
We all learn differently, and we all have our own strengths and weaknesses. For both kids and adults, it’s important to remember that school success and standard academic achievement are not the same thing as intelligence, and how you do in school doesn’t determine how you’ll do in the rest of your life!
I’m always looking for examples of successful individuals who dealt with learning disabilities or a diagnosis like ADHD, Asperger’s or autism. One such list can be found in the article Ten Celebs Who Suffer From a Learning Disability. Others lists like this can be found through Google or Yahoo searches.
A few local notes of interest to those here in the San Francisco Bay Area’s East Bay. California State University, East Bay is offering a variety of reading skills, reading comprehension, study skills and speed reading classes this summer in Danville and Walnut Creek. These classes include programs for ages 4 up through adults and college students. For more information, call them at (800) 979-9151.
Some of my regular readers may be aware of my concern about the vast quantity and poor quality of homework that fills our children’s time, not to mention the tremendous pressure kids are under these days. For a moving and thought provoking look at this topic, please make an effort to see the locally produced documentary Race to Nowhere. The film will be shown in Danville, California, on June 1st, 2010 at Monte Vista High. For information, and other screening times and locations, visit the Race to Nowhere website.
As I discussed in my previous post on managing procrastination and distraction, getting lost in the details can make it very difficult for anyone to finish, or even start, a project. For those with ASDs or ADHD, this can be even more troublesome. One technique I’ve found to be useful for many clients is to create some sort of visual plan of the project. Taking time to think about the goal, organizing the details, and jotting it down on paper will give you something to refer back to while working.
Here’s an example of a simple outline you might use to stay on track while completing a project. I’ve chosen the topic I’m working on right now: writing this post. (I’m typing this for the blog, but I’d only scribble it down in real life.)
Goal: Writing a Blog Post on Procrastination and Distraction
1. Reread previous post on this topic
2. Consider steps involved
3. Create examples:
A. Detailed list
B. Detail cloud
4. Find appropriate pictures to illustrate
5. Copy and paste document into blogging software
6. Create links and finalize details on blog
Here’s an example of a less structured detail list. You can make the more important steps larger and bolder.
Goal: Writing a Blog Post on Procrastination and Distraction
Find Pictures Reread previous post
Publish Create links
Copy and paste into blogging software Plan steps involved
That’s it! These are both pretty straightforward and it only took a minute or two to put them together. Now, while you’re working you’ve got a very clear idea of what you should be doing to accomplish the job.
If you decide to pet the dog:
or get a snack:
it’s pretty clear that you’re off topic. But, I think it’s more frequent that people get pulled into the details, and then wander around off topic. Finding a picture of an apple can turn into sorting through all the pictures in the photo library, or wandering from topic to topic in an internet search. That’s where the list helps. You’ve determined the goal: writing a post, and browsing internet photos has nothing to do with that. It’s a clear example of when you need to pull yourself back to work.
If you’re more auditory than visual, recording a list can be helpful. Whatever works for you is fine, just take a few moments to plan, set a goal, and then check back with your plan frequently.
Patricia Robinson MFT
I'm a licensed therapist in Danville, California and a coach for Asperger's and ADHD nationwide. I work with individuals of all ages who have special needs, like Autism Spectrum Disorders, ADD, ADHD, and the family members and partners of special needs individuals.