1. David D Nowell PhD www.DrNowell.com 2. www.DrNowell.com DavidNowell DavidNowellSeminars 3. Overview Perspectives ADHD overview Comprehensive ADHD evaluation Comprehensive treatment of ADHD Ask 2 questions Strategic behavioral inquiry (HDDT) Tools you can use now 75 strategies that just might change your life 4. Overview Perspectives ADHD overview Comprehensive ADHD evaluation Comprehensive treatment of ADHD Ask 2 questions Strategic behavioral inquiry (HDDT) Tools you can use now 75 strategies that just might change your life 5. Overview Perspectives ADHD overview Comprehensive ADHD evaluation Comprehensive treatment of ADHD Ask 2 questions Strategic behavioral inquiry (HDDT) Tools you can use now 75 strategies that just might change your life 6. PERSPECTIVES 7. A strategy has no stand-alone value 8. Whats wrong with this brain model? 9. Whats wrong with this brain model? 10. Whats wrong with this brain model? 11. Avoiding the most common diagnostic error 12. ADHD OVERVIEW 13. The Executive Functions Nonverbal working memory Verbal working memory Self-regulation of affect/motivation/arousal Reconstitution Barkley, RA, Murphy, KR., Fischer, M (2008). ADHD in Adults: What the Science Says . New York, Guilford Press. 14. The Executive Functions Nonverbal working memory Verbal working memory Self-regulation of affect/motivation/arousal Reconstitution Barkley, RA, Murphy, KR., Fischer, M (2008). ADHD in Adults: What the Science Says . New York, Guilford Press. 15. The Executive Functions Making movies in your head Talking to yourself Being your own boss Thinking and creating what could be 16. Arenas of Involvement Intrapersonal Interpersonal Environmental Academic / symbol system (McCloskey & Perkins, 2013) 17. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 29 1. 1-step errands 2. Chores with cues 3. Basic inhibition Preschool 18. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 30 1. 2-3 step directions 2. 20-30 minute assignments 3. Follow rules/inhibit/no grabbing Kindergarten - 2nd Grade 19. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 31 1. Simple shopping list 2. Keep track of variable daily schedule 3. Inhibit and regulate even without teacher present 4. Simple delayed gratification (phone) 3rd-5th Grade 20. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 32 1. Complex chores 2. Organizing system 3. Time management 4. Self soothe 5. Manage conflict 6th 8th Grade 21. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 33 1. Independent with assignments 2. Make adjustments based on feedback 3. Inhibit reckless behavior 4. Say no to fun activity if other plans already made 5. Take others perspective Teenage-mid 20s 22. Knock 3 years off his age 23. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 35 Lending Your Brain 24. Model and discuss attending Broad versus narrow Internal versus external Passive and active 25. ADHD and Brain Development 26. ADHD Inattentive Hyperactive Combined 27. DSM-V Changes Age of onset (12 years rather than 7) Adult criteria (5 symptoms rather than 6) Additional symptom examples provided Strengthening of cross-situational requirement Provision of comorbidity with autism 28. ADHD Inattentive Sluggish Cognitive Tempo Hyperactive Combined 29. Sluggish Cognitive Tempo Daydreaming Easily confused Staring Easily fatigued Sluggish Withdrawn Slow to complete tasks Lower levels of parent stress Less situation-specific than hyperactive type 30. ADHD and Brain Imaging 31. Environmental Influences Screens Second-hand smoke Toxic exposure Sleep deprivation 32. Environmental Influences Screens Second-hand smoke Toxic exposure Sleep deprivation 33. Functional impact of core symptoms Arousal / alertness Mental effort Determination of saliency Focal maintenance 34. Sleep hygiene Strict bedtime Use bed only for sleep No caffeine after mid-afternoon No activating media after 7pm 35. Establish bedtime routine 36. Fidget supports 37. Functional impact of core symptoms Arousal / alertness Mental effort Determination of saliency Focal maintenance 38. Premack Principle 39. Reward small units of effort 40. Functional impact of core symptoms Arousal / alertness Mental effort Determination of saliency (whats in it for me?) Focal maintenance 41. Theres no such thing as procrastination Theres just choosing.and choosing again 42. Increase salience 43. Increase salience 44. Functional impact of core symptoms Arousal / alertness Mental effort Determination of saliency Focal maintenance 45. EZ-C Reader 46. Dont stealth bomb inattentive students Pete in about a minute Ill ask you about.. 47. Functional impact of core symptoms Satisfaction control (post-synaptic dopamine insensitivity) Inhibition Tempo control Self-monitoring and correcting 48. DRO Differential Reinforcement of Other 49. Fail-proof desk activities Appendix A 50. Meet with your ADHD employee for regular ongoing feedback 51. Functional impact of core symptoms Satisfaction control Inhibition Tempo control Self-monitoring and correcting 52. Theres no such thing as disinhibited 53. The talking stick 54. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 101 Provide prosthetic cues at the point-of-performance (Barkley) 55. The talking stick 56. Functional impact of core symptoms Satisfaction control Inhibition Tempo control Self-monitoring and correcting 57. Functional impact of core symptoms Satisfaction control Inhibition Tempo control Self-monitoring and correcting 58. Distraction delay training 59. What are our data sources? Record review Interview Collateral interview Checklists Mental status examination Test scores 60. COMPREHENSIVE ADHD EVALUATION 61. Curious Compassionate Nonjudgmental Evaluation Skillfully eliciting the chief complaint HDDT? Forming a diagnostic impression Defending your diagnosis / impression 62. Skillfully eliciting the chief complaint Too much of what? Or too little of what? Invoking the Pediatric Fairy (or the Psychiatric Genie) 63. HDDT? How exactly did you do that? Everybodys doing the best he/she can Every behavior problem is either Skills deficit Contingency problem 64. Forming a diagnostic impression Where do you see it the most? And where do you see it the least? Two disorders = two stories 65. Documenting and communicating your conclusions The footprints in the butter Defend your diagnosis 66. COMPREHENSIVE ADHD TREATMENT 67. Comprehensive ADHD Treatment Medication Behavioral Support Working Memory Training Movement Vestibular and Cerebellar Interventions Neurofeedback Breathwork / meditation Creative visualization Mindfulness Bodywork Supplements / diet Hypnosis Coaching Counseling 68. Does it work? Does it make sense? 69. Comprehensive ADHD Treatment Medication Stimulant Non-stimulant Off-label treatment 70. Image: wikimedia commons 71. Cortico-striatal loop 72. Increase salience 73. Two weeks from now, how will you know whether its working? Appendix C 74. Daily report card Appendix B 75. Comprehensive ADHD Treatment Behavioral Support 76. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 151 A ANTECEDENT B BEHAVIOR C CONSEQUENCES 77. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 152 A ANTECEDENTS B BEHAVIOR C CONSEQUENCES 78. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 153 A ANTECEDENTS Set them up for success 79. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 159 A ANTECEDENTS B BEHAVIOR C CONSEQUENCES 80. choice architecture 81. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 165 A ANTECEDENTS Provide prosthetic cues at the point- of-performance (Barkley) 82. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 167 A ANTECEDENTS Identify exceptions Where do you see it the most? Where do you see it the least? 83. Rules Waking up Bedtime Chores Homework TV / internet A ANTECEDENTS 84. Launching Pad 85. Expectations Specific Behavioral In advance A ANTECEDENTS 86. Communication Get eye contact Speak clearly Provide behavioral info Check for understanding A ANTECEDENTS 87. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 186 A ANTECEDENT B BEHAVIOR C CONSEQUENCES Behavioral Support 88. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 187 B BEHAVIOR A healthy high- functioning 26 year old 89. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 188 90. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 189 B BEHAVIOR More Behavioral control Choices and options Self-regulation Arousal Motivation Mood Attention 91. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 191 A ANTECEDENT B BEHAVIOR C CONSEQUENCES 92. Dont reward them with stuff 93. Rotate rewards frequently 94. Determine what basic provisions are unconditional Love Respect Safety 3 meals Essential clothing Temperature-controlled environment 30 minutes of video games 95. and which are contingent Special foods Expensive or trendy clothing Extra video game time WiFi password 96. Clip and share horrible articles about teens falling out of the back of pickup trucks Review cause and effect Discuss consequences Emphasize behavioral agency 97. Working Memory Training Auditory integration therapies Brain gym CogMed Lumosity 98. Movement Techniques Exercise Rhythm and timing and cognition Integrated movement Yoga Martial arts 99. Turn 30 minutes into 45 100. Balance screen time and green time 101. Movement Techniques Exercise Rhythm and timing and cognition Integrated movement Yoga Martial arts 102. Bal-A-Vis-X 103. Vestibular and Cerebellar Exercises Dyslexia Dyspraxia Attention Treatment Interactive metronome Sensory integration 104. Saggar et al (2015) 105. Vestibular and Cerebellar Exercises Dyslexia Dyspraxia Attention Treatment Interactive metronome Sensory integration 106. Provide multiple cues for transitions Verbal two minute warning Visual schedule Changes in lighting Nonverbal cues 107. Consider your own self-stim strategies Applying lotion Clicking pen Sewing machine leg Gum Whistling 108. Instant study carrel 109. Time in 110. Heavy work 111. ADHD and Central Nervous System Overstimulation The caveman and the angel Breathwork Meditation Creative visualization Mindfulness Neurofeedback 112. Dr. Sara Lazar 113. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 237 114. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 238 115. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 240 116. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 242 117. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 243 118. The art of planning and extending our will through time - Robert Grudin 119. 1 hour 1 day 1 week 1 month 1 year Time Horizon 120. ADHD and Central Nervous System Overstimulation The caveman and the angel Breathwork Meditation Creative visualization Mindfulness Neurofeedback 121. ADHD and Central Nervous System Overstimulation The caveman and the angel Breathwork Meditation Creative visualization Mindfulness Neurofeedback 122. Bodywork Massage Chiropractic Transcranial magnetic stimulation Acupuncture 123. Supplements and Diet Omegas Food additives Food allergies Pesticides Dietary recommendations 124. Supplements and Diet Omegas Zinc Food additives Food allergies Pesticides Dietary recommendations 125. Nutrition essentials Emphasize protein at every snack and meal Eat fewer processed foods Choose local Choose colorful Pay close attention to patterns between food and focus/mood 126. ADD Coaching 127. Comprehensive ADHD Treatment May be expensive 128. Prepare your budget with your ADHD in mind Smaller car or apartment? Entertainment or wardrobe choices? What percentage of your budget will be directed towards ADHD supports? 129. Consider online peer support www.reddit.com/r/ADHD/ 130. Counseling Goals with the ADHD Client Basic Brain Supports (without these the rest may not matter) Sleep Nutrition Exercise Family Supports (any ADHD treatment should include support for the spouse or parents) Rules Expectations Communication 131. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 274 A ANTECEDENTS B BEHAVIOR C CONSEQUENCES Rules, Expecations, and Communication 132. The self-esteem abacus 133. Counseling Goals with the ADHD Client Therapeutic Interventions (traditional counseling tasks) Self-esteem Self-efficacy Lend-Me-Your-Brain Interventions (executive function support) Reading skills Study skills Time/goal management Calendar To-do list 134. The Big Five Daily focus time Nutrition Movement Sleep Connection 135. 10-Minute Morning Review 136. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 280 the most important 10 minutes of the day. 137. The Big Five Daily focus time Nutrition Movement Sleep Connection 138. Barter Social/Practical Support Food prep for optimal nutrition Domestic organization Pre-tax paperwork 139. The Big Five Daily focus time / Motivational clarity Nutrition Movement Sleep Connection 140. Exercise for focus is different from "exercise for fitness 141. The Big Five Daily focus time / Motivational clarity Nutrition Movement Sleep Connection 142. The Big Five Daily focus time / Motivational clarity Nutrition Movement Sleep Connection 143. Marry well and get a crackerjack assistant at work 144. The ADHD Couple 145. The ADHD Couple: The Problems The ADD Partner May Have: High need for stimulation Poorer impulse control Inattention to detail The Non-ADD Partner May Have: Rigid style Mild anxiety Unrealistic expectations 146. The ADHD Couple: Counseling Goals Remembering what drew you to your partner Realistic expectations Managing blame Getting to fair Feeling your contributions are valued Outsourcing Communication skills training 147. Positive characteristics of many people with attentional / executive challenges Appendix D 148. The ADHD Couple: Counseling Goals Remembering what drew you to your partner Getting to fair Outsourcing / professional supports Feeling your contributions are valued Communication skills training 149. Allow your non-ADHD partner or roommate to tackle longer-term projects: You take on more of the easy/quick tasks. 150. Dont do anything for your ADHD partner or teenager which could just as easily be managed by a machine or an app 151. Walk Me Up app 152. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 303 A ANTECEDENTS Provide prosthetic cues at the point- of-performance (Barkley) 153. MORE STRATEGIES THAT JUST MIGHT CHANGE YOUR LIFE 154. Tickler System 155. Why Dont Nuns Worry about What to Wear? 156. Strategy to rule to habit Lets spend 30 seconds right now determining where youll put your keys from now on upon entering your home. 157. Strategy to rule to habit 3. habit 2. rule 1. strategy 158. Take Advantage of Natural Systems When do you know its time to toss veggies out of the fridge? 159. Create (Just Slightly) Unnatural Systems Use a small in-box Use a small magazine caddy Schedule social events in your home 160. Upstairs downstairs box 161. Clear (see-through) storage 162. Clear (see-through) storage 163. Model and practice self-talk Im checking email then returning phone calls When do I need to be ready? How long will this take? 164. ASK TWO QUESTIONS Self-talk proficiency 165. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 337 Am I having fun now? Is this important? 166. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 338 167. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 339 168. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 340 169. What does dopamine feeeel like? 170. Yes Yes No Yes Yes No No No 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 359 Am I having fun now? Is this important? 171. Yes Yes No Yes Yes No No No 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 360 Im having fun. Im on task. Am I having fun now? Is this important? 172. Yes Yes No Yes Yes No No No 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 363 Im having fun. Im not on task. Am I having fun now? Is this important? 173. Beware dopamine tricksters! Facebook Gambling Shopping Video games Free online Aramaic course 174. Determine in Advance When Youll Check Email and Facebook Tomorrow 175. The best defense against the manipulation of our attention is to determine for ourselves in advance - how we want to invest it. - E. Goldberg 176. Key features of a great planner system 177. Key features of a great planner system 2 pages per day Master to-do list With the client at all times 178. Yoga / read Staff meeting Planning session Phone calls billing 179. Vh: jeff w/ puritan oil Vc: kate re: brimfield TC umass dermatology. Spoke w/ cindy 508 8564000 180. Key features of a great planner system 2 pages per day Master to-do list With the client at all times 181. Whats a To-Do list for anyway? 182. Use your brain for creating, not storing 183. Key features of a great planner system 2 pages per day Master to-do list With the client at all times 184. Key features of a great planner system The technology The practice 185. Key features of a great planner system The technology The practice 186. Weekly Overview 187. 10-Minute Morning Review 188. Where will I most likely feel distracted today? 189. What will you do today that you'll still remember one year from now?? 190. Stop 5 times a day for reflection and reconnecting and re-focusing 191. Yes Yes No Yes Yes No No No 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 408 Im not having fun. Im on task. Am I having fun now? Is this important? 192. Increase salience 193. Use extrinsic reward creatively 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 414 194. Emphasize the sensory details of your desired outcome 195. easy hard If Its Harder than a 3 Find Some Way to Make It Easier 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 419 196. Assign separate due dates for smaller parts of big projects 197. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 423 198. Yes Yes No Yes Yes No No No 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 427 Im not having fun. Im not on task. Am I having fun now? Is this important? 199. STRATEGIC BEHAVIORAL INQUIRY 200. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 437 201. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 438 December 2014 202. Objectives of SBI Specific behavioral strategy What was the feeling-goal? Motivational level on a scale from 1-10 203. Benefits of SBI Affirms the value of clients unique internal experience Emphasizes the culture of self-regulation Encourages metacognition 204. Assumptions of SBI Everybodys doing the best they can Behavior is not incomprehensible or random Behavior follows patterns which reveal themselves to the curious observer free of prejudice or blame or theory 205. How to do SBI How exactly did you do that? 206. Managing homework 207. 6/2/2015 2011 David D. Nowell, Ph.D. All rights reserved. 454 208. Personal Application 209. and How Exactly Did You Do That? 210. and How Exactly Did You Do That? 211. Personal Application What bad habit persists? And How Exactly Do You Do That? 212. ADHD and Insight 213. Fall in Love with the Truth Self-monitor and collect data: How long does your morning routine take, exactly? How much time exactly do you need to complete expense forms? How, exactly, do you follow through on commitments to others and not to yourself? 214. Learn from your To-Do list Which things are not getting completed? How exactly are these not getting completed? How do you do that? 215. Clinical Application Who in your clinic or classroom is demonstrating remarkable resilience persistence despite significant obstacles? And how, exactly, does he/she do that? 216. Clinical Application Who in your clinic or classroom is demonstrating remarkable resilience persistence despite significant obstacles? And how, exactly, does he/she do that? What recurring behavioral problem is showing up in your clinic or classroom? 217. Clinical Application Who in your clinic or classroom is demonstrating remarkable resilience persistence despite significant obstacles? And how, exactly, does he/she do that? What recurring behavioral problem is showing up in your clinic or classroom? Note: we arent asking why did you do that, but rather how exactly did you do that. 218. Lets stay in touch! Join my e-newsletter list: Fill out a card today and drop it in the box. Sign up on my web site or Facebook page Visit us on the web: www.DrNowell.com @davidnowell David Nowell Seminars 219. Set alarm early sometimes but not always 220. Place the student with tactile defensiveness at the edge of the group 221. Energy of Activation 222. Broad band and narrow band treament