The Neuroanatomy of ADHD and thus how to treat ADHD - CADDAC - Dr Russel Barkley part 3ALL

So let me show you how we can build a model of ADHD from the neuroanatomy and neuropsychology of ADHD to understand ADHD we have to understand how normal self control develops and then we'll show were ADHD affects it there are three concepts that we need to build this model One inhiibtion you have to stop and build a pause in your behavior as your mother said stop and think before you act in the stopping comes first or as Rabalais said everything comes to those who can wait but whoever said the fact is that what distinguishes human cognition from all other species is we wait weekend decouple and avenge stimulus from our response to that event other species cannot do that and bite decoupling them we can do things in the delay that others cannot do but the first thing we have to do is stop now in addition can be defined as three separate capacities all of which are impaired in patients with ADHD the first is the ability to inhibit the urge to respond on the moment to the event this is the impulsiveness the dish in addition the second however is the ability to interrupt in ongoing behavior when it's time to do something else that's two percent variation and that is also an inhibitory failure you can't stop what you were doing particularly if it was interested if it was rewarding to shift to something more important but where the consequences might be delayed finally there is the ability to protect your frontal lobes you're working memory your what and went systems from destruction from interference from being perverted disrupted and distorted by events around you that have nothing to do with the goal you're pursuing you must be able to suppress those unwanted reactions notice that the distractibility in ADHD is not a perceptual issue it isn't inhibition problem people with ADHD don't perceive distractors any more than others the difference is they respond to them they get up and they react to the irrelevant event another of task and once they're off past they can't retain the goal so now they will return to the task so it's simply a series of responding to irrelevant events in life which is why it is so hard to accomplish your goals all three of these are failures up the innovation system and people with ADHD as we well know have trouble with all three now the next concept we need to build up our model is not just in addition but self-regulation what isn't self-regulation is very simply defined as it was forty years ago by Skinner and others as involving three steps the four-step we've already talked about you don't stop but having stopped you will now direct a behavior back at yourself you will engage in some action that is aimed you not the world not others back it yourself you doing something what are you doing you trying to change your behavior from what it would have been had you simply responded on impulse so there's a form of shelf change going on here I'm acting on myself to change my next response why would I want to do that to change a distant consequence I am trying to alter the future I'm not trying to change the now in fact I may use this as an opportunity to turn away from the seduction zav the moment from the immediate rewards the feel-good aspect of life I may turn away from that and subject myself to adversity and poverty for years to change that future call going to college you you've given up the job the money the car the close the babes in everything right and you can live in poverty for at least four years because if you can get that degree you're gonna earn ten to fifteen thousand dollars more a year than people who didn't at a distant consequence all deferred gratification requires self-regulation action to the self that's changing yourself that altering your future okay now the third concept we have to discuss is what then is an executive function we've been talking about the executive system but we haven't defined now this is interesting because if you look anywhere in a row psychology there is no definition I've looked actually wrote a review paper seven years ago on the amorphous nature up the concept no one defines it they will give you a list of testing think that measured like Wisconsin card sort or they will give you a list love what they think are the functions themselves in addition non verbal working memory verbal working memory the central executive and so on but just a list right it's not a definition so that operationally define a in my theory Ave tht we define an executive function as what you doing to yourself the action to the self that first step in our definition of self-regulation that is an executive function and action to the self designed to change you so as to change your future and there are five actions that humans will direct it themselves which means there are five executive abilities may be more but we know of at least five so self control isn't one thing its five things and each of them can be called an executive action put them all together you got the executive system and by adulthood you should be using all five of these to get to the future so we can now link all of these together in addition links up with self control because you can't direct connection it yourself if you don't stop responding to the world you can't do both at once you can't react when event and control yourself at the same time you have to stop doing this one to come back and change urself and self-regulation the jump with executive function obviously because self-regulation is comprised a5 types of self control each and executive function these are going to develop one at a time they're going to take thirty years to develop and each of them is going to need the one before it to develop before it consumption so it's a hierarchy think it is a pyramid the first began to three months of age and right along with it comes the second not is in addition and the nonverbal system now neuropsychologist have labeled the used by these useless terms that you see here non verbal working memory what the hell is a verbal working memory emotional in addition that's a little more obvious planning and problem solving what is that so what I did in 1994 was after reading papers by by god's key Jacob renounce key lauria and others my specialty is neuropsychology hence the reading I began to see an idea that was taking shape that could be used to help us understand and redefine each of these executive functions because she forgot he had already developed a model of how language goes from being a public action to others to the voice in your head so I stole my God he's idea and I simply said this must be how all the executive functions develop actions to others turn back on the shelf and slowly made internal private can we redefine each executive function as an action to the self absolutely and by doing so we get a much clearer picture up what we're doing with this executive system also just as an aside we also get a much better picture of how they evolved how do you get from a primate brain to human brain this model can explain it the earlier neuropsychological terms cannot so what action are you doing to yourself in terms of non verbal working memory you are seen to yourself it is the visual imagery system and humans have the best system for holding images in their mind any species on this planet and check by 12 months of age you exceed all other primates and from there you will have 10 more years to let the system develop you have a theater in your mind a DVD player up the past which you can activate on-demand to see which you have previously done if it would be useful to do so the layman's term for this is hindsight you activate images have the relevant cashed and you hold them in mind and that's the non verbal working memory system but you can also use the other centers to yourself you can hear yourself you can taste yourself you can feel to yourself I can describe the wine I had with dinner last night over at the Delta hotel by just visualizing the dinner Henry tasting the Cabernet if I didn't do that I couldn't describe it to you so the image comes first and then the description by the way this is how you can tell people about all the yesterday's have your life but wasn't for the images you couldn't say anything the words require the images but it isn't just the images I can re sense everything I can really hear the conversation with my waiter and I can really feel the texture of the napkin for the food or whatever I can replay the whole event right appear in this theater simply put this is the mind's eye the ability to hold images in mind and as William James said a hundred years ago it is the secret to the human will to understand the human will one only needs to hold an image in mind because from that image everything else flows as a consequence so the first executive function besides stopping is to re image the relevant past hindsight will say more about that in a moment the next executive function his speech to the self the bike got skin model I'll teach you that one those three are going to lead to the next one you can remote to yourself you literally can create emotions de novo in yourself there was no other species it can do that finally you internalize your manual play and it becomes the source of the highest executive function which is planning problem-solving and simulating multiple possible responses and you can do it all appear and it's situated at the foremost frontal pole it has the capacity to manipulate what you are holding in mind and not display the nice thing about this model is it tells you why childrens play is so crucial to adult planning and problem solving because manual play moves to symbolic and mental play and that's the source of all human Planet as I said he to the use develops in a stepwise sequence creating a hierarchy up the executive system now this is the bike got skin model so let me explain it to you because what i'm arguing is that each of these executive abilities follows the same sequence so let's take speech between 0 and three years of age according to my God he's turned out to be correct young children emit language to others there is no cell speech and there certainly is no voice in his head but between 5 sees me three in five years of age you're going to see this young child talk to themselves and apt is measurable you can video tape 3- to 5-year-olds engaging in a lot of self-directed outward speech they are just little chatty Kathys effect if you put two 4-year-olds together it's not a conversation its parallels of speech and if you put this kid to bed at night you're going to hear them talking in the room even though nobody's there right you are witnessing by got peace theory in action between five and seven you're gonna start to see the face being suppressed along with the larynx and the utterances you'll see children do this the mouth still moving but you don't get to hear the utterance now speech at this point is going to change in three fundamental ways when you get quieter as I just illustrated and it's going to be telegraphic once in a while a word slips out that is perceptible but the most important changes going to be going from description young children described their world to self instruction they start to tell themselves what to do and at this point it starts to work below five years of age anything a young child tested themselves has no function it doesn't work so they could be sitting there saying stop stop stop stop and I'll keep playing video games language has not yet captured the motor system but by five to seven it has what you say starts to control what you do and that is why it's there between nine and twelve years of age this voice is entirely in the mind but we know that it still based on shelf speech because the research done in the last decade let me give you an example I can put electrode all over your face and I can ask you disliked to shake your not say Canadian Pledge of Allegiance in your mind used in with your face the muscle movements are so small but the imperceptible to you and two others but they're measurable the human face is moving anytime you engage in verbal fight social lyrics by the way but you can't see it I can't see it but we can now measure it all verbal thinking his speech to the self with the face suppressed but you can suppress an entirely little electrical pulses are coming out and their activating the muscles around the face in very Jerry subtle ways you can ask an athlete to engage in a visual image up in action let's take a diver or how about just somebody picking up something and throwing it across the room you know that when you imagine that we can measure your right are moving it it really moving but the muscle potentials are all changing in the exact sequence that would be needed to throw that ball this is why you can use visual imagery to improve athletic performance because you're using the same system there is no separate system you've just kept the actual brain activity from going down the spinal cord but using the same part of the brain when you talk to yourself you use the speech system but the only thing different between talking to you in talking to me the to suppress your motor strip still the same speech system which is why you can't talk yourself and talk to other simultaneously because it's the same damn system right but you just keeping it in your head attorney trip so it helps us to understand what I got he was talking about here really shouldn't be called internalization should be called privatization because you're developing the capacity to inhibit public actions and to keep them in the brain and that gives you a sense of something mental cognitive but it still action to the self no matter what now the first executive function therefore that's going to appear three months of age is the innovation system and it is going to shut down that motor system because right along side it is going to come the visual imagery system and it needs you to stop what you're doing to hold images in mind too that those images can start to take over your behavior so the first two executive functions Co develop simultaneously and by about 12 to 14 years a page they've reached their adult level of development you get no more after that they are early arising by the way there's a rule in biology that the earlier a function emerges the more important was to the survival that species telling us that as humans visual imagery in in addition played a very crucial role in human survival by three years of age you get that I got game system and now you have to mean to controlling your behavior images and words those are going to lead to the third system you are now going to use those images and words to create your own emotional state you are no longer depending on the environment around you for your emotions and then finally you will internalize your play and it becomes a source of planning creativity innovation and problem-solving by the way that's goal-directed creativity not just artistic musical there's a goal to be attained you can count on an obstacle can you solve the obstacle can you invent multiple possible ways around the obstacle to accomplish that goal and that's based on human play by thirty years of age you have this entire system functioning unless you have ADHD and then you have a thirty to forty percent lag in this entire sequence the five executive abilities I just described are going to shift your behavior from the left to the right as a three-year-old you're being managed by external events around you as a 30-year-old you better be being regulated by your thoughts by what you are anticipating by the things you hold in mind but to ship from external to internal control that is going to lead you away from being controlled by Others which three-year-olds art to self-management you no longer need other people to wake you up in the morning for instance that is going to lead to a third shift you're going to go from being preoccupied entirely with the now to increasingly being concerned about the future and the older you get the further out you anticipate this is gonna go from being a matter of a few hours in early elementary school to about eight to 12 hours by age 7 rate to about two to three days by adolescents to 12 weeks by the time you're an adult by age 30 the average decision made by the average adult on the average day is eight to 12 weeks that's how far out the average adult anticipates the future or they can anticipate it further out if that's necessary but on average our window on time is two to three months just look at your calendars you'll see when you start to rate things in them that is going to change your behavior from being concerned only with immediate consequences to being concerned with delayed consequences deferred gratification so to summarize this executive system is there to help him self regulate and organize your behavior across time to anticipate the future and the future you anticipating is the social future the frontal lobe is a social organ as diamond argued it is the sheet of our social intelligence it is where we regulate our social behavior and it probably emerged initially as a basis for social cooperation because we do something very few species do we live with other members of our species with whom we may not be related and we share we cooperate reciprocate but most importantly we keep score you don't think so just stopped repaying your favors and see how many friends you have on test your friendships real quick if you stop reciprocity so let's take a look at these executive functions very quickly because we're getting a very good idea what they do the visual imagery system the ability to sense to yourself which comes very early is probably the basis for all human social exchange we use images to keep track of who we owe and who owes us and we can usually keep track of about 200 250 people in that frontal lobe you have a giant Excel spreadsheet in your frontal lobe and it is for bookkeeping you use images I've the past in order to understand who you paid who owes you how much when and what it's worth but if you can hold images in mind even if it originated for this kind of reciprocity in cooperation you can now copy the behavior of other people because all imitation and bike here is learning is based on holding an image of what other people do in your head and if you can do that you can use other people's behavior as your own you don't need to learn things anymore you could just watch people and by watching what they do and what happens you can use what you saw to change yourself by the way is a go through this list each of these as a deficit created by ADHD there's an interesting prediction children with ADHD can not use the behavior of others to change their own behavior they can't use the experiences they witness to all to themselves oh they sought it just doesn't matter other kids can be punished for fighting on the playground this job loss of light they will have to experience life first hint so they're going to hit the Hard Knocks a lot more often than other people this is the system that let you look back to look ahead to get ready hindsight foresight and anticipation a future events ADHD children are not going to be doing that very well and if you look back to look ahead you get a sense of time and now you know why ADHD destroys the sense of time adult ADHD is the consummate disorder of time management and that's because people with ADHD cannot use percent of time which part of the frontal lobe deficit the second executive functions of speeches where we talk to ourselves this is where we reasoned with ourselves we self question we saw of direct rules to ourselves where we internalize the instructions given to us by others were the ones we create ourselves and they work they serve to guide our behavior in a rule governs fashion people with ADHD will find language to be very weak at influencing their behavior until adulthood they will be delayed in the ability to use words language and instructions as a form of guidance which is why they don't do what you tell them to do not willful disobedience it's a failure language to control the motor system but this is also the source of reading comprehension because if you can talk to yourself in your head you can hold the word you reading in mind and that leads to a deeper comprehension what you've read heard were seen so we should find it adult ADHD is associated with a progressive deficit in comprehending what we read see and here and then of course internal rules are the basis for morality so we should find some delay in the ability to morally govern our behavior we've talked about the emotion motivational system so I won't go any further into that this is where we modify our emotions and create our motivational states which is the basis for persistence self-discipline willpower finally the ability to internalize are playing gives rise to the ability to generate multiple options when we are faced with the problem and if this system isn't working very well people tend to fall back on over learned outdated ineffective behavior by the way the system also involves putting behavior together to solve the problem stringing a sequence of actions together so we should see that people with ADHD have a lot of trouble with problem solving in their mind with generating multiple possibilities for getting things done and then with following the one that most effective in doing so but we should also see that they have trouble stringing behavior together in a proper sequence and we will see there's no better than in their speech ask a high school student with ADHD to stand up and tell you what they read in history last night and you will get massive dis fluency this is what it will look like history I think I read that yeah I did I know I did okay um it in Boston I'm sure that and there's a guy with the horse yeah there's a person there something about a church in some lanterns give me a moment gotta love horseback riding us-led forces we go to charlottesville virginia every summer man is at a cool place cuz we have our storm down there and you know when you're there if you go there they're searching casting barbecue place right at the corner of the downtown and what did you ask me you're laughing because what you have just seen are two executives share yours I couldn't hold the goal in mind that's working memory and I could not assembled the behavior to attain it and that's this module so what do you get you get the correct statements the concrete superficial out of sequence and finally the goal is lost and the conversation has wondered so you will see a lot of certainly Putian in verbal wondering in ADHD adults because they lose the goal they were talking about and then they can sequence the information very well either by the way you'll see this in writing you'll see this in speech in to see this and behave what does this mean for ADHD in didn't ADHD is not an attention disorder it's a blind as to the future it is a myopia to the impending future events you are nearsighted in time which means that the child and adult with ADHD are going to wait until the future is imminent and then they will try to deal with it but as long as the future stays out there I don't have to deal with that the closer it gets the more I'm going to organize toward it but I can't really do much about it until it's the 11th our and I will race around try to slap things together in a happy dash manner to get it done ADHD creates an nearsightedness two-time so that the person with the disorder can not organize to the delayed future but only to the imminent future and so everything in life becomes a crisis but the crisis was avoidable and no one has any patients with us because they see this as a moral failing you could have chosen to get ready but you didn't it is phrased as a former the laziness this layabout near do well carefree care less attitude did you could change if you wanted to me but we know it as the executive share your it really is this disorder precludes you from organizing across time so you live in the moment and you cannot organized Jerry large hierarchically sequenced behavior across time it means that future direct behavior is intentional behavior which means ADD is actually ID'd intention deficit disorder I don't seem to be able to accomplish most to the things I intended to do you can call that a short attention span but I think intention deficit disorder captures that much better now the Frontalot the executive system is where you take what you know and you apply it in your daily life it is not where you know something it is where you use what you know the back part of the brain acquires knowledge the front front part of the brain put it in play ADHD has separated these two like a meat cleaver so it really doesn't matter what you know you can't use it as effectively as other people can ADHD is a performance disorder you can't perform the things you know how to do it is not a knowledge disorder most people with ADHD know about as much as anybody else from their neighborhood with their education at school at that age but they can't use it not to anywhere near the degree of effectiveness of others so people with ADHD know what to do but they can't do what they know one of the things we have known in neuropsychology is if you wish to treat an executive disorder a performance disorder the only way to treated is to change the pointer performance the point performance is the place out there in life we are you should be using this knowledge and for some reason you can't seem to do it so all treatment must be at the point performance and if it's not it won't work no amount of treatment done away from that place will solve that problem only changing that place will solve that problem you have to restructure the environment to help them show what they know so what does this mean it means a teaching skills as a waste of time because they will be used skills or knowledge and these people already have motor skills anyway but even if you teach the new into the likelihood that they will get implemented is pretty slim I can hand any adult Alicia time management recommendations and I can guarantee you the most to them will never get used in fact the paper will be lost on the way home because it will blow up under the front seat of the car and then you'll forget that it's there or if you do remember that if they are not able to the refrigerator but you won't look at it and if you do you say you know I really should be doing those things these are really cool things this is what I really need help with and then I'll just go about behaving impossibly anyway you know come back and say you know doctor partly those were great ideas did you do the Welsh I'm working on it point and find that hard to DC Entertainment this is not a knowledge disorder it never once it's a problem with using what you know and no shita paper correct her performance December you have to design the point performance around the individual the phrase we like to use is designing prosthetic environments we're going to use prostheses little artificial things around the patient in order to help them I'll give you some suggestions in a moment but let's remember that the most effective treatment is done with the problem occurs not away from the problem this means that medication is going to be needed for most cases have ADHD because we now know how medications altered genes in the brain to change these neural networks so the drugs like the stimulant in at a March 13 are actually forms of genetic therapy they literally Armada Armada fine the neuro genetic impacted the disorder in the brain unfortunately like insulin they only do it temporarily only while they're in the bloodstream in the brain and once they wash out the brain goes back to being the executive deficit brain that it was previously but this gives a very clear rationale for why medications are essential for this disorder this is not a socially created construct that we're using medication is a band aid to paper over as if we were putting mental straight jackets on people with ADHD medication can now be rephrased as near a genetic intervention now I just made a case for being excused from the consequences of your actions but I really haven't because you see in this theory the most important thing is not the consequences it was the delay to the consequence what hurts people with ADHD is that most natural consequences have any importance or delayed and the longer they're delayed the more disabled you become so the way to do with ADHD is not to dismiss consequences that would make it worse it is to tighten up the accountability to bring those consequences closer in time more frequent for immediate more serious accountability over time that's what we're going to talk about in my next lecture so the point here isn't to dismiss accountability is to take that up individuals with ADHD need more not less accountability so we're gonna need to modify point to perform in turn create little prosthetic devices and behavior modification becomes one means I'm doing so so you now know why we have to do behavior modification because it creates artificial environments that weren't previously there in order to compensate for these executive deficits but because we have to change the natural environment the success in any treatment is contingent on the compassion other people in that environment how willing are they to help you modified appointed performance and if they're not on board and if they're not willing or compassionate can be very difficult not impossible but quite difficult so we come to view ADHD there for like diabetes on long-term chronic disorder they can be successfully managed but it requires modifying environments lifestyles behaviors up the individual so a chronic disability viewers ADHD as a much better view then the attention deficit view I V DHT so to summarize we can think about ADHD as a disorder in addition that disrupts the executive system and leads to failures and self-regulation and since the purpose of the executive system is to organize overtime and get ready for the futures in life that is what ADHD is robbing the individual of a capacity to do organized across time to the future now how can we change that point a performance well if you can't hold things in mind put them outside a few you need to externalize key pieces of information at these crucial point in life this is where sticky notes charge list card reminders PDA's computers anything you can think about okay you're the issue here is not what you do its why you have to do it ADHD has destroyed the working memory system you can't hold things in mind so don't right them down 10 most effective things an adult with a DG can do is carry a journal that is changing your body if necessary and in it you will write what you agree to do and what others tell you to do and Zach is your working member you are going to use an external resource to compensate for an internal working memory problem so whether it's digital memory recorders whether it's a journal whether it's card whether it's notes you need to do it I remember being picked up once at the airport in Cedar Falls Iowa by a drug rep who was adult ADHD a friend of mine and I got in the car ni pick me up and I looked at the dashboard and I was stunned you know what was on the dashboard sixty sticky notes sixty rate spread all over the dashboard now I understood that he had always noted the pointer performance and they were in the right sequence in which he had to call on these various doc and get things done what concerned me to know when is he covered the speedometer damn a I knew I was in trouble and rent as we will see in my next recent Asian driving is a major problem but the point is this the more externally represented the information is the more compelling it is and the more likely it is to elicit the action you need to do you need to be using external props and choose however you do it now you have no internal clock that you can reliably call upon you have a distortion in the internal sense of time so you're going to need external temporal references young children will need cooking timers older adults may need watches that vibrate and go of it varies hours you may need computers with outlook that signals you 20 to 30 minutes before a deadline but you're gonna need to use external temporal guidance devices things like week at a glance calendars PDA's and other means organizing your life but time must be represented externally and not just rely on your internal some tough time you cannot anticipate that future and deal with it across time so the best thing to do is to break the future into pieces into a piece today and other people can help you do this so take the long term goals break them into their baby steps go back to those little many behavioral structures I showed you but the frontal lobe is supposed to be organizing the higher-level structures and do step a day a sequin today and then you can have baby steps across time and when the future gets here you're ready all of that will be for nothing if you don't have some external means of motivating you to do these things so you need to arrange for consequences around you for getting things done when the best way to do that is to make yourself accountable to others got social consequences can be very motivating but you may also need to arrange other privileges other rewards that you find interesting valuable in ordered for you to get your goals done and these things need to be soon immediate don't tell yourself that if I work for a month I'm gonna allow myself to one by some new clothes or get some iPhone or iPod or download a musical whenever this need to be something within the day not outside today near you bring the consequence more motivating it will be you also need to use manual problem-solving so if you have things that need to get done instead of just doing them in your head try to do them with your hands as much as you can as well take mental arithmetic instead of striving to do would appear you could be doing it with physical things you could have marbles a number line in tobacco so hit calculator or the calculator in the laptop you're going to need some external means a representing and manipulating the problem so however best you were able to do that try to do so but this is how you solve the five executive difficulties by going backward in their development they were want external they have become internal we need to make them external once again if we do that along with medication you should be able to compensate for these executive problems but if you persist in viewing ADHD as an attention disorder you will learn nothing thank you very much

Channel: Adhd Videos

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Keywords: Attention Deficit Hyperactivity Disorder (Disease Or Medical Condition), Russell Barkley (Author), Dr Russell A Barkley, CADDAC, Executive Function, Working Memory, ADD, ADHD, Attention Deficit Disorder (Disease Or Medical Condition)

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Length: 37min 55sec (2275 seconds)

Published: Tue Sep 02 2014