Understanding and Supporting Clients with Attention Deficit Hyperactivity Disorder

David D Nowell PhDwww.DrNowell.com

Understanding and Supporting Clients with Attention Deficit Hyperactivity Disorder

www.DrNowell.com

DavidNowell

DavidNowellSeminars

Overview

• Brief definition of ADHD

• ADHD evaluation and treatment

• The “Big 5”

• Ask 2 questions

• Strategic behavioral inquiry (HËDŸDT)

• Q & A & D

Overview

• Brief definition of ADHD

• ADHD evaluation and treatment

• The “Big 5”

• Ask 2 questions

• Strategic behavioral inquiry (HËDŸDT)

• Q & A & D

BRIEF DEFINITION OF ADHD

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.


• 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.


• Making movies in your head

• Talking to yourself

• Being your own boss

• Thinking and creating “what could be”

12/10/2014© 2011 David D. Nowell, Ph.D. All rights

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1. 1-step errands

2. Chores with cues

3. Basic inhibition

Preschool


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1. 2-3 step directions

2. 20-30 minute assignments

3. Follow rules/inhibit/no grabbing

Kindergarten -2nd Grade


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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


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1. Complex chores

2. Organizing system

3. Time management

4. Self soothe

5. Manage conflict

6th – 8th Grade


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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 20’s

Knock 3 years off his age


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Lending Your Brain

ADHD and Brain Development

ADHD and Brain Imaging

ADHD

Inattentive Hyperactive Combined

What are our data sources?

• Record review

• Interview

• Collateral interview

• Checklists

• Mental status examination

• Test scores

COMPREHENSIVE ADHDTREATMENT

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


• Medication

– Stimulant

– Non-stimulant

– “Off-label” treatment

Image: wikimedia commons

Cortico-striatal loop

Increase salience

Two weeks from now, how will you know whether it’s working?

Appendix C


• Behavioral Support


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AANTECEDENT

BBEHAVIOR

CCONSEQUENCES


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AANTECEDENTS

BBEHAVIOR

CCONSEQUENCES


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AANTECEDENTS

Set them up for success

Meet with your ADHD employee for regular ongoing feedback


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AANTECEDENTS

Identify exceptions

Where do you see it the most?

Where do you see it the least?

Rules

•Waking up•Bedtime•Chores•Homework•TV / internet

AANTECEDENTS

Willpower depletion

Launching Pad

Communication

•Get eye contact•Speak clearly•Provide behavioral info•Specific•In advance

•Check for understanding

AANTECEDENTS


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AANTECEDENT

BBEHAVIOR

CCONSEQUENCES

Behavioral Support


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BBEHAVIOR

“A healthy high-functioning 26 year old”


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BBEHAVIOR

More

• Behavioral control• Choices and options• Self-regulation

• Arousal• Motivation• Mood• Attention


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AANTECEDENT

BBEHAVIOR

CCONSEQUENCES

Determine what basic provisions are unconditional…

• Love

• Respect

• Safety

• 3 meals

• Essential clothing

• Temperature-controlled environment

• 30 minutes of video games

…and which are contingent• Special foods

• Expensive or trendy clothing

• Extra video game time

• WiFi password

Working Memory Training

• CogMed

• Lumosity

Movement Techniques

• Exercise

• Yoga

• Martial arts

Turn 30 minutes into 45

Balance screen time and “green time”

The Caveman and the Angel

• Creative visualization

• Mindfulness

• Neurofeedback


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© 2011 David D. Nowell, Ph.D. All rights reserved.

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Mindfulness

Mindfulness

Supplements and Diet

• Omegas

• Food additives

• Food allergies

• Pesticides

Nutrition essentials

• Emphasize protein at every snack and meal

• Eat fewer processed foods

• Choose local

• Pay close attention to patterns between food and focus/mood

ADD Coaching


– May be expensive

The “Big Five”

• Daily focus time

• Nutrition

• Movement

• Sleep

• Connection

10-Minute Morning Review


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…the most important 10 minutes of the day….

The “Big Five”

• Daily focus time

• Nutrition

• Movement

• Sleep

• Connection

Barter Social/Practical Support

• Food prep for optimal nutrition

• Domestic organization

• Pre-tax paperwork

The “Big Five”

• Daily focus time / Motivational clarity

• Nutrition

• Movement

• Sleep

• Connection

“Exercise for focus” is different from "exercise for fitness”

The “Big Five”


• Nutrition

• Movement

• Sleep

• Connection

Sleep hygiene

• Strict bedtime

• Use bed only for sleep

• No caffeine after mid-afternoon

• No activating media after 7pm

Establish bedtime routine

Fidget supports

Consider your own self-stim strategies

• Applying lotion

• Clicking pen

• Sewing machine leg

• Gum

• Whistling

The “Big Five”


• Nutrition

• Movement

• Sleep

• Connection

Marry well and get a crackerjack assistant at work

The ADHD Couple

Allow your non-ADHD partner or roommate to tackle longer-term

projects: You take on more of the easy/quick tasks.

Don’t do anything for your ADHD partner or teenager which could just

as easily be managed by a machine or an app

“Walk Me Up” app

ASK TWO QUESTIONS


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Am I having fun now?

Is this important?


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What does dopamine feeeel like?

YesYes

NoYes

YesNo

NoNo


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Is this important?

YesYes

NoYes

YesNo

NoNo


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I’m having fun.I’m on task.


Is this important?

Master these for awesome time management:

• Appointments

• To-do items

• Habits

YesYes

NoYes

YesNo

NoNo


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I’m having fun.I’m not on task.


Is this important?

Beware dopamine tricksters!

• Facebook

• Gambling

• Shopping

• Video games

• Free online Aramaic course

There’s no such thing as procrastination

• “There’s just choosing….and choosing again…”

Determine in Advance When You’ll Check Email and Facebook Tomorrow

StayOnTask app

Key features of a great planner system


• 2 pages per day

• Master to-do list

• With the client at all times

Yoga / read

Staff meeting

Planningsession

Phone calls

billing

Vh: jeff w/ puritan oil

Vc: kate re: brimfield

TC umass dermatology. Spoke w/ cindy 508 8564000


• 2 pages per day



What’s a To-Do list for anyway?


• 2 pages per day




• The “technology”• The “practice”


• The “technology”

• The “practice”

Weekly Overview

10-Minute Morning Review

Where will I most likely feel

distracted today?

What will you do today that you'll

still remember one year from now??

What are the activities you do NOT schedule? And why not?

Strategy to rule to habit

3. habit

2. rule

1. strategy

In review:

• Appointments

• To-do items

• Habits

The “talking stick”

There’s no such thingas “disinhibited”

YesYes

NoYes

YesNo

NoNo


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I’m not having fun.I’m on task.


Is this important?

Increase salience

Emphasize the sensory details of your desired outcome

easy hard

If It’s Harder than a “3” Find Some Way to Make It Easier


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Assign separate due dates for smaller parts of big projects

Use extrinsic reward creatively


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Premack Principle

1 hour 1 day 1 week 1 month 1 year

Time Horizon

“Modified Independence”

• Chronic disability perspective

• Providing support at points of performance

• Prosthetics

Distraction delay training

Reward small units of effort

Increase salience

YesYes

NoYes

YesNo

NoNo


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I’m not having fun.I’m not on task.


Is this important?

STRATEGIC BEHAVIORAL INQUIRY


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Objectives of SBI

• Specific behavioral strategy

• What was the feeling-goal?

• Motivational level on a scale from 1-10

Benefits of SBI

• Affirms the value of clients’ unique internal experience

• Emphasizes the culture of self-regulation

• Encourages metacognition

Assumptions of SBI

• Everybody’s 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

How to do SBI

“How exactly did you do that?”


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Personal Application

…and How Exactly

Did You Do That?

…and How Exactly

Did You Do That?

Personal Application

• What bad habit persists? And How Exactly Do You Do That?

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?

Learn from your To-Do list

• Which things are not getting completed?

• How – exactly – are these not getting completed? How do you do that?

Clinical Application

• Who in your caseload 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 caseload?



• What recurring behavioral problem is showing up in your caseload?

• Note: we aren’t asking “why did you do that,” but rather “how exactly did you do that.”

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Health & Medicine

Understanding and Supporting Clients with Attention Deficit Hyperactivity Disorder