2012 Burnett Lecture Part 2 ADHD, Self-Regulation and Executive Functioning Theory

firm as if it's the most popular thing since sliced bread and then we go about assessing it but the ways we assess it through tests don't measure anything of significance in human life so how do we resolve this problem well one thing is to throw out the test as I've said another thing is to try to think about a theory of executive functioning that might preserve some small limited role for testing but clearly it would not have the importance that it currently has in making decisions about people's lives and that's what we're going to do now now 15 years ago I began drafting a theory of ADHD as a disorder of executive functioning and self-control so I'm going to quickly go through this because this has been around now for 15 years and those of you in the audience who follow ADHD you probably already know this but for those of you who aren't bear with me I need to just do some background teaching here the first thing we need to know is that executive functioning is self-regulation that is the most common trait ascribed to these ef-s that we call them they are essential for our self-control that is the number one attribute across all definitions all descriptions there's something about EF that lets us control our own behavior I think that's a great starting point because in 1956 BF Skinner give us a definition of self-control which survives to this day it's very good very specific has three parts we know it when we see it self-control is as you see here anything you do to yourself an action that you direct not at the world but at you you are doing something to yourself why to change yourself from what otherwise you would have done so you're trying to modify your own behavior now why would you want to do that no other species does that with two exceptions right you're trying to change a distant consequence a delayed outcome you're trying to change the future you're trying to alter the probability of something happening or not by adjusting your own behavior accordingly so any self directed act that is used to change your behavior so as to alter the likelihood of the future very simple very easy that's what self control is now all I did was to take this and say we can use this to define executive functioning how can we do that the executive functions are the things you do to yourself what are you doing we know that humans direct at least seven different activities back on themselves to modify their own behavior to change their future so self control isn't one thing it's seven different things in each specific type of self control is an executive ability so there are seven executive abilities because there are seven self-directed actions and they all go together to give us our modern mature adult self control I want you to think of it this way this the executive functions are the Swiss Army knife of the frontal lobe you've got seven little mind tools up there that you are using to manage your behavior over time to change the future that's coming at you so that it is more consistent with your welfare so that you can delay gratification and we know in life that the delayed rewards are the important rewards they're usually the bigger rewards so we can then say that an executive ability is what you're doing to yourself what is that thing you do now neuropsychology calls them these names but we can read to find them as something you're doing to yourself and get some value added from that we know that they develop in a sequence they don't all come at once and we know that each of them is a form of activity you do to yourself and by the time you're an adult they're private their mental their cognitive they're in you can't see them anymore but in young children when they first begin to appear their observable their public and then what children do over the next decade or more is they start to make that private they suppress the body so that what they're doing in their brain no longer enters the spinal cord humans have deep in their brain a switch and it determines whether what you're doing in your brain leaves the brain as it does in all other species or whether it stays up there to become cognitive mental private that's all it is public private you have two selves that switch is probably the basal ganglia but that's not important what we know is that humans have a way of behaving privately that other people can't see now where did I get this idea from 40 years ago or more probably 50 Vygotsky the great russian neuropsychologist developed a theory of how we go from speaking to others to a voice in our head known as the internalization of speech it is a well founded theory it is well researched it is now accepted in development there's nothing hypothetical about this this is how you get a voice in your head that you use to talk to yourself all day long most of the time the talking is private but when you're home alone and no one is around sometimes you make it public you sing to yourself in your car and while you're doing dishes and vacuuming and you're telling yourself what to do out loud and the somebody else comes into the room and private again you're still talking up there I just can't hear you right so the way the sequence goes very quickly in case you're not familiar with it is between 0 and 3 this is my grandson right Jake this is Liam you know him well right Liam has started talking and that's all him can do he just talks to everybody talks labels points things out describes his world its language to others there's no voice in the head there's no self-talk it's just language but between three and five years of age Liam will be three Thanksgiving and I'm watching him real close I think he think was starting to show some of this early because he's so precocious oh sure he is right all right so what liam is going to start to do is limas going to start to talk to himself whether anybody's in the room or not and even if you're in the room it doesn't matter you're going to see a lot of self speech it's still audible videotaped easily just put him to bed at night and you're going to hear liam talking to himself so that's going to go on for two years speech directed back at me doesn't do anything it's just description there's no voice in the head and it doesn't control him by the way what a child says to themselves has no controlling function until after five and then it starts to get some traction prior to that time what children say they're going to do is up for grabs we don't know whether they're going to do it or not okay language does not guide behavior until after five years of age that is self language not other people's language self language okay but now between five and seven something interesting is going to happen here not only are we going to see Liam talking to himself but we're going to see three changes first Liam is going to go from describing his world to giving himself commands he's going to start to tell him what to do put it here over there no I don't think that's gonna why don't we try over the second thing that we're going to see Liam do is what he says to himself is actually going to start to guide his behavior it's going to start to govern him the third thing we're going to see is that he's going to start to suppress his face and you're going to start to see this the vocal cords are being suppressed the face isn't yet but over the next couple of years Liam will be able to suppress his entire facial structure and larynx so that he can talk in his brain using the same speech centers but it doesn't come out he is going to have the voice in the head now we know this is how he gets it because researchers can take an adult like me put electrodes all over your face and ask you to cite the Pledge of Allegiance in your mind and your face is moving you don't know it you can't feel it I can't see it but we can measure it these muscles are moving the movements are so subtle it takes very sensitive equipment to pick it up but that's what you're doing everything you say to yourself is associated with movements of the face but you have this break in your brain this switch that is suppressing those signals so they don't leave the brain you're talking to yourself and you're using the same system you would use to talk to me but you're keeping it in the head we know how this sequence goes on and we know that this gives you your mind's voice and that you use your mind's voice to guide yourself all day long for the rest of your life it's not there to keep you company on a lonely day it is there to govern you right and it does so all I did was to take that sequence behavior to the world gets turned back on yourself and then is made private as a form of self control and I said every executive function does that this is the one we know the most it's the one we know the best but it's not the only one so if I get any credit it was stealing vygotsky's process in saying every single executive ability follows that sequence this just happens to be the fourth one there are three that preceded what are they the first which comes very early at three months of age and takes more than a decade to mature if you turn your attention on yourself what do you get self awareness only humans redirect the attention system on what they're doing all other species use their attention system to monitor their environment but you don't you also direct on yourself you watch what you do and you monitor it all the time you now have a little executive perched up there that watches yourself keeps an eye on what you do and self monitors so the first thing you human does is to redirect their attention Network back on themselves and they get a sense of self of self-awareness over time the second thing they do is they inhibit that motor system self-restraint and you can see children do this physically right but as they get older they don't need to do it motorically anymore they can just do it up here right they can stop themselves volitionally this is known as executive inhibition you know it as self-restraint you can stop yourself from doing things if you have to so it's effortful takes time so you got this one very early by the way then you get the next one psychology calls this non verbal working memory but following vygotsky's process we have to redefine it as what are you doing to yourself and the answer is obvious humans see to themselves this is visual imagery and it starts very early you have a Theatre in the mind and you can replay images of your relevant past anytime you need to to guide you through what is about to happen next you have a GPS in your brain and just like a GPS up comes an image that image serves as a map that map guides you over time to your goals these three develop simultaneously they are so important to our survival and welfare that they start early and they peak within 10 to 15 years so these are the first three that we ever got you sent to yourself mostly its vision but you can rehear retouch retai stry smell if I want to tell you about the wine I had with dinner last night at the Carolina in I will reach a stat wine right now and talk to you about that Cabernet how else could I tell you about it the words are meaningless without the image the image comes first then the explanation no explanation so consequently humans resurrect images of their past all the time and they use it to guide them through what is about to happen it's always the relevant past if I want to get back to where my car is parked I'm going to retrace where Theresa and I walk this afternoon and that's going to get me back to where I need to go I am showing resenting my past and using it as a map as a guide and then you get the next one at five years of age you start to talk to yourself now you have four mind tools self attention for self awareness self restraint visual imagery and private speech you got the first four EFS underway right now amazing but now you're going to get three more because those four lead to the next ones you can now use those four to manipulate your emotions you can literally create new emotions in yourself de novo there is no species that can do this and everybody else emotions are provoked but not in a human because a human can provoke their own emotions and good actors know it through the method School of Acting if I am Meryl Streep and I am filming Michael Cunningham's movie the hours and I need to weep I need to grieve there is nothing on a movie set that you would grieve what does she do she calls up an image of her past in which she did have a legitimate grief reaction and the image brings the emotion they are welded tight together they are not different they are unity images have emotions welded onto them some of them are mild others are profound if I recall the death of my brother and his car accident six years ago I will be in big trouble up here so I'm not going to do it because even now just saying it my heart rate changes my face flushes I start to get a little tearful and my breathing changes notice what happens the very uh pterence of the image brings the emotion right along with it so humans use these to modify their emotional states why would you want to do that because you live with other people and emotions can be very offensive in you need to build up networks of friendships and cooperative groups with people you have got to manage your emotions because they will drive other people away from you and the other reason that you have to do it is emotions our motivational States and if you can manage your emotions you can manage your motivation you don't need BF Skinner giving you a token or an M&M you can create your own motivation I don't need anybody else I can write whole books that take years and I won't see royalty payments for another year and I will still stay the course nobody is standing over me saying here's a token for every sentence that you write rest right you are the only species that can do this every other species needs a consequence and had had better happen in seven to ten seconds or the game is over every other species is Skinnerian stimulus response and consequence but not a human because a human can replace external consequences with mental representations and in so doing motivate themselves what a little children do when they're asked to wait in order to get a prize a toy a marshmallow as Walter Mischel showed in his experiment 30 years ago on delay of gratification what do they do they imagine eating the marshmallow and they talk about it and then they can sit there staring at the marshmallow man that's going to be so good you wait man when I go camping we toast these over and we make s'mores and I'm creating my own motivation to get across the delay in time to get the consequence we self motivate which is why we don't need external consequences like other people do so we use these to manage our emotions and our motivational States and then you get the last one right up here at the very pinnacle of the frontal lobe and you call it planning and problem-solving and what it really is is private play all adult problem-solving is founded on children's play and that is the reason children play it is not for entertainment though it has that value it is preparation for adult problem solving children learn to manipulate their environment and to play around with it to see what happens and to take it apart and recombine that is what play is let's see what happens right that reminds me of a joke down in South Carolina about what's the last word a redneck says before he dies watch this sorry hey they told it to me I didn't know that before I move don't film by me okay the point is this this little mental problem solver you have up here it's internalized play you are taking apart and recombining images and words in your mind to solve problems but that's all it is it's play analysis synthesis take apart recombine it starts out as manual I have to touch the world but eventually I don't need to touch the world I literally can tell you how to take this apart and put the batteries in it why because I can manipulate all of the parts in my head I can imagine the recombination this is the source of human imagination it's also the source of every invention ever invented right there right so now by adulthood you have a profound set of tools you're aware of yourself you have self-restraint you can see to yourself and sense to yourself and hear to yourself but you can also talk to yourself and you can use all of these you Moute and motivate to yourself and then you can play with all of that information take it apart recombine it see what happens all up here you are the most inventive species that has ever lived on this planet and that's where it came from that's the executive system all I did was to redefine them as actions you do to yourself and don't tell me you don't do these this is self-evident I just made the connection so now that gets you up through 1997 by the way another way of looking at the executive system is a two-part system this is the automatic brain any animal with a spinal cord and a minimum brain has this this is stimulus response something happens you attend to it you will praise it you'll respond it's all automatic it's all unconscious you don't need a cortex to do this right the automatic brain if you want to read more about this distinction Daniel Kahneman's new book Thinking Fast and Slow is about these two levels but then you get this one self-awareness you're now monitoring the automatic level and then you develop these and you use them to guide that system whenever necessary the executive level takes over the automatic level whenever it needs you most of the time most of the day you're operating down here you don't need executive functioning for everything but sometimes you do novelty things that involve time they're not familiar with there's a delayed consequence you will engage this system so it's just a different way of looking at it now when this executive system starts to emerge we're going to see that what governs a child's behavior is going to change over the next thirty years of their life it's three years of age you're going to see people being governed over here this is where Liam is right now he's under the control of external events there are no mental events he's under the control of others my son and his wife specifically right he lives in the temporal now Liam does not talk about yesterday and tomorrow he doesn't even know what the heck those are right Liam is in the now right no three-year-old plans this Friday or Saturday or Sunday right but as he develops he's going to move over here and then finally all Liam cares about is what's in it for me right now what do I get now Liam doesn't care what you're offering tomorrow or this afternoon or next week it's all here so no if it isn't there it's out of his mind he has no idea what you're talking about but over the next thirty years this is what's going to happen people are going to go from being governed by external events to the events they hold in mind working memory mental representations this is going to let them take over the control of their own behavior from other people they are becoming self-reliant self-determined and self defensive this is also going to lead them to start to get a window on time they're going to start to look ahead a few hours a half a day a day three days and so on so if you're a three-year-old you're not looking ahead by five it might be an hour or two by seven it's about twelve hours because that's when you tell your mother you need art supplies tomorrow morning it's when she talks you into bed at night and then it becomes two or three days when you're a teenager which really ticks your parents off because they're looking ahead a couple of weeks and all you can think about is the next day or two you are living in your own window on time it doesn't matter about what other people's time horizon is and then when you get to college it's about two to three weeks and then when you hit thirty years of age it's two to three months that is the average window that the average human has on their future over which you make the average decision you can look further out if you have to I said the average time horizon is eight to twelve weeks and that's what you're starting to plan for some of you have booked your tickets for Christmas some of you have started shopping some of you are planning New Year's right how do we know we collect your calendars I'm looking when you start making entries this is not hypothetical you get a window onto the future and as that window develops you start to prefer later consequences over immediate consequences because they're bigger they're better your life is much better if you look after your long term welfare than after just your immediate welfare so over the next 30 years we're going to watch Liam make these transitions and he's doing it because of his executive brain all right now you're up through 1997 I still haven't gotten you where I need you how do we take that model and walk it into everyday life your life my life other people's lives how do I go from that cognitive mental model of things you're doing in your mind to yourself and I get into friendships self-reliance I get into social relationships peer relationships family functioning how do we get any of these important domains and that's what I've spent the last 10 years doing until I wrote that book that's out there that came out in May I now have gotten you into daily life and it's called an extended phenotype it's very common in biology to look at how the phenotype of a species radiates out to affect its environment and that is what it does the conventional view of a phenotype is it's anything that ends at the skin it's your hair color it's your eye color it's your height and these days we now talk about the havior we know that certain behaviors have a genetic basis to them certain ability certain talents have genetic basis to them so part of our current view of a phenotype goes out to our behavior but that's where it ends when we think about genotypes and the phenotypes they produce we kind of stay close to the skin this is what you learned in biology but that is not where biology goes because biology has now extended out those predispositions into effects at space and time at a distance phenotypes radiate their effects into the ecology all around the species and to the extent that those distant effects come back to influence your survival your reproduction and your welfare they are part of your phenotype let me show you a few examples there are birds that build colored nests in order to attract mates they create artifacts in their environment and it helps with their reproductive success because other female birds like these colors that are being woven into the Bower bird's nest that nest is part of the bowerbirds phenotype so with the colors that it chooses so is the shape of the nest there is genetic variation in birds nests in a birds genotype we have now reached into the environment manipulated the environment and created something that didn't exist there and that's part of our phenotype we do this too we manipulate our environment all the time then there are species that actually alter entire ecosystems like a beaver which chops down trees and drags them to a waterway and dams up a stream which creates a pond which then changes the entire ecosystem so that other species can live there that couldn't previously and it even changes the weather pattern over the area and to the extent that this benefits the beaver and its offspring it is part of its phenotype there is genetic variation in beavers for the size of the ponds that they build that is part of the beavers phenotype you don't think of it that way but it's true right there are species that invade other people other organisms like the rabies virus and it goes into its brain and it manipulates the nerve cells in the brain to take over that species and alter its behavior for its own welfare and it makes you salivate and it makes you affectionate and it makes you go around and licking other children and eventually it makes you aggressive and it makes you want to bite things all of which is it the benefit of the rabies virus because it's through the bite that it's going to transmit itself to the next generation the rabies virus has an extended phenotype and it goes into the brain of other mammals and it takes it over and manipulates that brain to its own advantage but that rabies virus does in your brain to change your behavior is part of its phenotype people don't think of it that way but it is there is variation in the rabies virus for the behavior of its hosts and how to alter that behavior to promote the virus and then there are species that use chemical signals to takeover and manipulate other organisms a very good example is there's a male Mouse that when it gets near a pregnant female emits a pheromone and you know what that pheromone does it causes the female Mouse to abort the fetus is that it has so that she comes into heat and the new male can now breed with her male mice have a chemical signal that alters the body of a female Mouse and brings her into ovulation after she aborts well you can bet that female mice have evolved defenses but they're not perfect so there is variation in the male Mouse for a female's behavior so you don't have to invade another species to manipulate it you can do it through chemicals and there are many species that do it through auditory and visual signals they start manipulating other species around them and even their own species when you hear frogs croaking at night this is what you hear it is also what humans do and we do it through images art music and language my lecture is an attempt to manipulate the mental content of your brain I have jumped the gap between us using an auditory signal but I am manipulating your brain as much as if I injected a draw into that nervous system still the same changes no drug so notice how species can actually act on their environment not just on the physical environment through artifacts like birds nests but through the behavioral environment of other species we can literally manipulate others to our advantage and that is part of the extended phenotype okay now you know when an extended phenotype is it looks like this if we were to look at its effects there's your genes there's the structures they build there's the functions they serve there's the behavior they create there's the effect they have on other environments material environments physical environments there is the effect on other species and so on the genotype radiates out sometimes from miles outside of itself to influence its ecology to its own benefit so that's what an extended phenotype would look like and those are the layers out there humans have one final layer out here and it's our culture we create scaffolding around us using the inventions of other people and we invent our own stuff if we need to to help you understand where we're going to go with this with it how do I use this for executive functioning I want you to think about driving driving in people is a very complex mechanisms a very compact set of behaviors right it's like executive functioning is very complicated and the only way to understand driving is to view it as a series of levels and you got to have all of the levels to understand driving so here is a model of driving I know I do driving research or I did write the first level of driving is not driving it's the basic mental functions you have to have to drive vision hearing motor speed reaction time alright you got to have those isn't that driving no but that's essential for driving if I want to assess your driving I would have to assess that level but that's not the only level I would assess if I did I couldn't predict your driving because then we go to the next level known as the operational level this is the level at which you learn about what a car is where are the brakes where are the mirrors where is the turn signal what's a seatbelt phone for how does that car drive when I take it into a parking lot Jake when you learn to drive you into probably Costco or Walmart or one of those and you just played around with the vehicle there wasn't anybody else around you were learning the behavior of the vehicle right that's the operational level of driving I need to assess that if I'm going to assess your driving but if that's all I assess what I understand you're driving know you're just driving by yourself in an empty parking lot I got to go to the next level called tactical I need to put you on the road with other people who also have vehicles and goals and destinations and plans and you guys are kind of going to come into conflict with each other at intersections so you need to learn the rules of the road and self-restraint and subordinating your interest to other people and taking turns there's a whole new set of abilities and skills that come into play here that you didn't need in the parking lot of Walmart you are driving the midst of other drivers which is why we call it tactical you're adjusting your behavior to theirs we're still not done I could assess all three levels it's still incomplete because the next level is called strategic and it answers the question why the hell you drive in the car what goals you trying to accomplish where are you going what are you trying to do how many different errands are you running what's the best sequence to do those errands in did you listen to the weather did you listen to the traffic are you paying attention to whether or not you need to alter your plan to accomplish your goals given the surrounding conditions as they play out it's the executive level of driving known as strategic now if I were to assess your driving I would need to assess all four levels if I assess this I would miss your driving and I couldn't predict it and it wouldn't correlate much with your driving ability so now let's come back to executive functioning all of the tests of executive functioning are here and it's no wonder they don't assess it because they haven't assessed the other levels and until they do the analysis is woefully incomplete so by using driving you can see that driving is a multi-level activity and to appreciate it in all of its beauty we have to assess all the levels not just one but that's what executive functioning people are doing they're assessing one level in a multi-level system so now let's build that multi-level system it's going to be based on developmental capacities as you grow up your frontal lobe expands forward as it expands you are going to start to see an improvement in your mental faculties first of all you're going to be able to string together much more complex sets of behavior and the further ahead in the brain you go the more complex the behavior becomes so there's a stretching of behavior into much more complex sequences why is that because you're trying to extend your behavior out over space as children grow up they start to involve themselves in things at a distance when they're very little like when Liam comes to my house he's only concerned about my family room that's where the toys are he's not thinking about upstairs outside the yard the people next door the cars on the street his mind is right here in this room but as he starts to grow up Liam starts to think about what is happening at a distance and whether that affects me or not and whether anything I can do might alter what's happening out there believe me I monitor our community Liam doesn't I know what's going on outside that house I know what's going on in my community and in my country I read the papers I want to know because we act at a distance he doesn't then you're going to get this one which I already talked about you're going to start to interact toward the future you're going to start to get a time horizon then you're going to start to prefer those delayed consequences and the older you get the more the delayed consequences are that you prefer but this is another one you're going to start to use more and more complex rules to guide your behavior now you're going to start to build up social networks you're going to start to make friends you're going to share take turns reciprocate interact with people you trust because by doing that you can accomplish things you can't get on your own share swap take turns and so on so this is the beginning of social skills but what it really is is the beginning of using other people as a tool as a device to improve both of us and we don't do this with everybody we're very selective in who we reciprocate with but that's reciprocity tit for tat taking turns the next thing up is you're going to start to build large social networks that do things simultaneously in groups and then finally you're going to start to use the culture around you to create your goals and to solve problems on the way to the goals you're going to start to reach out and take from the culture what you need to do what you want to do things like this so humans create culture and they adopt culture and they create scaffolding around them with that culture culture has just shared information shared artifacts but humans use it right so the further forward in the frontal lobe you go the more you're going to get these abilities the more the frontal lobe matures the more capacity you get now we're going to use all eight of those and build the phenotype the first level of executive functioning very similar to the first level of driving in Michaan's model are those mental abilities the things you do in your head those self directed cognitive actions talking to yourself seeing to yourself emoting to yourself and so on those are basic cognitive mechanisms but if I assess only those like with a test battery I could not predict your executive functioning because that's just level one you're not even close to getting to executive functioning so I now need to assess the next level we call it methodical self-reliant you start to take care of yourself you start to dress yourself feed yourself bathe yourself close yourself you start to protect yourself from being manipulated by other people you start to put a wall between you and others you start to become self determined and self-reliant and by the time you're an adolescent your parents hate this because they can't manipulate you the way they used to do by telling you what to do because you want to say it what's about to happen one of the things that we don't like as parents but that we should relish in our children is the development of self-determination because they are going to need that in adulthood when they get out there people are trying to manipulate you all day long to their advantage it's called advertising you are bombarded with efforts on the part of other people to alter your behavior to their advantage you have to put a wall between you and them so that you are not automatically gullibly manipulated by everything everybody says to you and that's this level I call it the Robinson Crusoe level of executive functioning if you lived alone on an island you would still need these things and you would especially need them when other people show up because they are not coming to be your friends the people who showed up on the Island of Robinson Crusoe were not there to be his friend right they were there to eat him yeah right remember the story of Friday was being chased by the other cannibals okay enough all right so this is the self-reliant self-determined self-defensive level of executive functioning right you have to assess that level but it's not enough because in a few years you get the next one you start to reach out and interact with others you trust you start to share you give to them they give back you start to subordinate your interest to theirs because they will to you and you start to build up friendships friendships are just tit-for-tat relationships among people who we trust but you're building a network of trustworthy people reciprocity sharing turn-taking all come in at this level this is also the basis of our legal system and it's also the basis of economics swapping goods and services with each other but we're not done yet because finally you get the top level you start to build groups of people who have a common goal who can't accomplish it alone this is not tit for tat this is acting in unison we all get together to build the barn for the Amish family down the street nobody can do that alone we all get together to clear the field of its stones you help me I'll help you but we have to do it together it's a cooperative enterprise it is the highest level of executive function because it's the basis of human groups communities governments all up here this is your executive system and this is how you get from things you do in your head to the most important things in human life are all right here okay now we can define when an executive function is executive functions are those self-directed actions that we talked about that you are using to choose your goals and to select an act and sustain your actions over time toward your goals those mental self-directed activities but you are doing those in the context of others relying on others and also using cultural means to do so and you do all of this to see to your long-term welfare to look out for yourself that's an executive function definition and it integrates executive functioning up through human daily social life as we live it throughout our lives so it looks something like this if you were to put it in a sort of stepwise stage-wise model you get this one then you get that then you get this then this then this and by the time you're grown up you can operate at all of these levels and as a result you are a successful effective happy self-supporting self-aware person who sees to their own welfare but does it cooperatively with other people as needed to do things you can't do on your own it looks like that so there's your radiating extended phenotype and we've now integrated it out with daily life activities what does a model like this mean for understanding disorders of executive functioning first of all it means that disorders like ADHD disrupt all five levels they're shaky they're Swiss cheese they're full of holes they're not working well you can't operate at all of these levels because your basic executive abilities those seven mental mind tools are not developing on time and when they do they're weak ineffective they're late so you can't do level one activities and as a result all the levels above there are now at risk the ability to become self-reliant independent self determined the ability to develop friendships and sustain them the ability to work in groups they're all at risk because level one is failing so you can begin to see that the system is going to start to collapse because the executive system is a future directed system it'll create a type of time blindness in the person when it goes wrong because its goal is to anticipate and get ready for the future and you're not you live in the moment you are nearsighted to time you are myopic across this timeline as a consequence time blindness is an excellent metaphor for ADHD and other PFC disorders you are adrift in time everybody else is dealing with it and you're just in there now and wherever there now goes that's where you go so you go outside to mow the yard on a Saturday true case story and you decide to mow the lawn and you push the lawn mower out but the tank is empty so you reach for the gas can it's empty when you shake it so you throw it in your Ford Explorer and you drive down to the shale kwik-e-mart and you're filling up the gas can and in pulls your fishing buddy and he says opening day on the trout stream got an extra pole what do you say couple hours you leave your car running you get into his car you guys go fishing after a couple of hours you guys are thirsty so there's a bar down the road the caters to fishermen who come and fish that scream and you go have a couple of beers and then you get back home at four o'clock in the afternoon and guess what the Massachusetts State Police are out looking for you because your wife called at 11:00 this morning wanting to know where the heck you were and they found your car running and a gas can open at the shell Mart down the street true story do you see what happened here as the now change you got pulled along by the now because these mental representations of the future of goals of tasks of time gone shattered soon as I pulled into that lot and said let's go fishin game over right that's what you lose you become blind to time blind to the future that means that that whole hierarchy is going to start to collapse friendships adaptive functioning peer relationships education work anything involving deferred gratification is at high risk if you have a disorder of your frontal lobe what you're going to see is a reduction in all eight of those capacities that that frontal lobe was gay I'll show you a diagram of that and this is going to affect everything you try to do toward the future so this whole system disappears and if you have a very severe disorder you don't have executive functioning your Phineas Gage it's over right so the more severe the injury all of these delayed by 40% if you have ADHD so that these aren't developing on time they're not going to get you where you need to be you're in big trouble so I want you to understand that you have a brain the back part of it is where you learn the front part is where you do knowledge performance knowing doing an ADHD splits them apart I don't care what you know you won't use it you can be the brightest kid in the world not going to matter so you got a real problem on your hands because you can know stuff and you won't do stuff that's a serious problem called a performance disorder so what we know about ADHD is it's going to put all five of those levels at risk because it interferes with all seven executive functions and you're going to have time blindness and you won't be able to aim your behavior toward the future to care for yourself as effectively as other people are able to do you have intention deficit disorder you have a disorder of performance not knowledge you know what to do but can't do it you have a disorder of the when and the where not the what and the how your problem is not with knowing what to do it's with doing what you know what does that mean it means that all interventions must be out at that place in the environment where you're not doing what you know to help you show what you know I have to create scaffolding around you to help you do this what does this mean for treatment teaching skills is inadequate it won't work you can sit down with somebody with ADHD and tell them what they need to do good luck right it's not even going to leave your office you act like they're stupid they're not they know what to do they know what you're telling them to do right they're not going to do it when they get out there that information has no controlling value over their life and it ticks you off you start to interpret it as a motivational problem but the only way to deal with executive deficits is to re-engineer the environment around them to help them show what they know and all treatments must be out there in their life where you have to build that scaffolding all of this in ADHD is due to neurogenetic deficits and that means that medication is absolutely justifiable after all if you have a neurogenetic disorder than neurogenetic therapies have a role to play in your disorder and they do 80% of people with ADHD will be on medication at some point in their life and good thing it's the most effective thing we have there are other things we can do but that's the most effective now you might be able to train up some of these executive functions we don't know that yet we don't know whether practicing working memory actually helped you in life there's no evidence that it does at this point at least convincingly but there's a possibility what we do know is we are not going to excuse you from your mistakes because the problem you're having is not with consequences so why would I excuse them the problem you're having is with the delay to the consequence all important social consequences are delayed consequences and that's your problem time so the solution to anybody's problem with an executive deficit is to tighten up accountability to make you more accountable more often to other people with more consequences artificial as they may need to be but I need to bring consequences very close to you in time so I'm not going to excuse your behavior I'm actually going to hold you more accountable than other people and that is why we do b mod b mod allows me to sprinkle artificial consequences all throughout the environment to improve your functioning and that means that the success of my intervention is based on the willingness of other people in the natural environment to make those changes if they're not willing to build ramps so to speak to build the scaffolding it's not going to work the stakeholders have to be involved it means that ADHD is the diabetes of Psychiatry it's a chronic disorder that must be managed every day to prevent the secondary harms it's going to cause but there is no cure for this disorder now about 1 in 6 people might outgrow it maybe as many as 1 in 3 not sure yet but the vast majority two-thirds are going to continue to be ADHD in adulthood and they need to view ADHD as diabeetus of the brain it's a chronic disorder so here are the things that my theory tells you to do to help people with executive deficits this is what I told you this morning this is the take home cash value of shifting your framework from an attention disorder to an executive disorder and the theory tells you all six things you got to do step one you have to make mental information physical you must externalize the information because working memory is shut that means we have to use cues signs charts reminders doulas I got to put stuff in your visual field to remind you of what needs to be done right here right now make it external again the next thing I have to do is make time physical real two clocks timers counters watch minders anything I can enlist that is going to put time outside of you so that you can see it passing and judge your performance relative to it because you have no clock we got to put one in your visual field I'm going to have to take lengthy assignments because they involve spans of time and get rid of time make them small quotas little baby steps over the bridge in time a little bit of work done frequently over time and will get you there but you will not do book reports and science projects and other things on your own you can't those involve delays and you can't handle delays so the best way to solve the problem is get rid of the delay and bring it back into the now through little steps break all long term projects into baby steps do a baby step a day you get there if you don't do that they're not doing it you have to make motivation external they can't create internal motivation they are dependent on the environment for their motivation you must put the consequences in the now or they will not work for you this is what video games do and what homework does not which is why they can play video games for hours and not do their homework for more than a few minutes video games provide external continuous reinforcement homework does nothing video games do not need X or internal motivation whereas homework duds so you've got to create motivation you're going to start to have to make a deal with your kids what's in it for them what are you putting in it for them what are you creating what's the reward what's the point what's the token what's the sex the drugs and money whatever it is you're going to have to negotiate a deal there has to be a consequence or it isn't going to get done you have to make problem-solving manual remember they cannot do mental manipulations like other people this is why they can't do digit span backward but that's nothing to do with digit span they can't hold things in mind and move them around as well as other people so don't make them do it put it in their hands if they have a math problem to solve give a marbles a number line and abacus a calculator let them do the problem manually or at least assist the mental problem solving with manual pieces to it it's the principle that matters people you can come up with lots of ideas here and then finally and this is the most important the executive system has a limited fuel tank and you can spend it out real quick every time you use an executive function and you use it continuously you empty the tank and if you get to the bottom of the tank in the next situation you will have no self-control this is the ADHD child after school gone and you want to do homework you're out of your mind so you got to refuel that tank and that tank has a very limited capacity so how do we refuel the tank interesting there are lots of things we have discovered to boost the tank the use of rewards and positive emotions the use of self statements of effectiveness I can do this I know you can do this this is the locker room pep talk before the game helps to boost motivation in addition to that you need to take 10-minute breaks very often indeed more often you need to break tasks down into smaller units and take frequent breaks and during those breaks a little relaxation and meditation helps to refuel the tank stop using the executive system for a few minutes and give it a chance to restore its fuel tank this is why we talk about the 10 and 3 rule with ADHD children 10 minutes of work three minute break 10 and 3 10 and 3 but you can't do more than 10 you're starting to empty the tank give them a chance to refuel the tank what does this say about keeping kids in for recess when they don't get all their homework that you just shot yourself in the foot and that leads me to the next thing visualizing and talking about the future rewards will help you boost the tank and so does physical exercise routine aerobic exercise boost the tank refuel zit and creates a bigger tank everybody with ADHD should be involved in an exercise program because research shows it benefits this disorder better than any other psychiatric disorder and now you know why it helps to refuel that tank and finally the fuel in the tank is sugar in the bloodstream in the frontal lobe blood glucose in the frontal lobe is directly correlated with executive abilities what does that mean if you have an extensive task involving your executive rein like an exam that you have to do you better be sipping on some lemonade or a Gatorade or a sports drink sipping not gulping you're going to have to keep your blood sugar way up so that you keep this fuel tank partially restored so this is the opposite of what people once thought sugar hurts people with ADHD no it does not and never did but it may well help them if it's in fluid form that can get into the brain very quickly you've got to keep that blood glucose up those are the things you can do to boost the fuel tank there are various approaches on the market for adults and college students with ADHD that incorporate these ideas Steve's are Russ Ramsay's program which is cognitive behavioral therapy does a pretty good job of it I'm not going to go through this with you Steve saffron's program even better because it's based on this model of executive functioning so Steve talks about what you can do to boost executive functioning and adults who are on medication but they have to be on medication and the most recent one came out this March it is the most heavily executive in nature it is Mary Solano's program for training executive functioning and adults with ADHD these are the three tested programs that have been shown to boost medication effects in adults with ADHD and all of them target those deficits in the executive brain as part of their models so what have you learned today you've learned that ADHD is not an attention disorder you've learned that it's an executive disorder that the executive system is a very complex multi-level system like driving it is not one level of cognition and that's all it is it's multi-level it's complex and it extends into our daily life you know that ADHD disrupts that system through behavioral inhibition and wiping out all the other executive abilities which puts you at risk for failing in your executive activities in your daily life people with ADHD have problems in all dimensions of executive functioning in their daily life and that is going to lead them to have great difficulty in getting along with other people building up friendships networks cooperatives subordinating their interest to others all the things in life that involve executive functioning from money management to driving to friendships to families and so on are at grave risk in this disorder because they all depend on this executive system so we are going to have to help people with ADHD build the scaffolding around them and use the medication as neuro genetic therapy with them in order to compensate for these executive deficits we're going to have to design prosthetic environments around them you know the beauty of ADHD is it's the most treatable disorder in psychiatry there is no disorder that we treat that has as many medications and as many psychosocial treatments that are as effective as these are for as many people producing more change than any other medications and psychosocial treatments for these individuals do you know that 55 percent of people on medication are normalized 90 percent of them respond do you know that the effects of ADHD medications are three times that of anxiety drugs and antidepressants that you all give away like candy in your practice we have huge effective drugs on our hands here that we can use and we also have very effective psychosocial interventions this is the most treatable disorder that we face the biggest problem is most people don't get treatment 40% of children and 90% of adults with ADHD are not recognized or treated for their disorder the problem not that we're over treating we are under treating and we're under treating the most treatable disorder in psychiatry thank you you are welcome right on time good shall I close the fire hydrants I know you're all going no Lord or I can't tell you could do so much information right luckily this will be on the Internet you need to go back and review it and you have your handouts as well so we are going to proceed with questions now we've collected your questions we've sort of them in the categories we've weeded out redundancy also these cannot be personal questions because that's unethical so we're going to try to keep them on the topic and not about a person and they're going to read them to me right okay wrong time

Channel: UNC Learning Center

Views: 175,805

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Id: QZpF2_IelWo

Length: 58min 44sec (3524 seconds)

Published: Thu Nov 01 2012