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www.DrNowell.com Lend Me Your Brain: Practical Strategies for Managing ADD/ADHD, Executive Dysfunction, and Processing Disorders DavidNowellSeminars DavidNowell

Perspective of this workshop…..

“Top – down” dysfunction ADHD Executive dysfunction

“Bottom - up” dysfunction Central auditory processing problems Sensory processing problems

Normal and Abnormal Sensory Processing and Attentional Functioning The Physiology of Motivation and Reward The Brain’s Reward and Planning System – and How that System Breaks Down A Practical Toolbox of Strategies Overview

Normal and Abnormal Sensory Processing and Attentional Functioning

Sensory Integration Terminology Sensory Processing

Developmental considerations Auditory . Visual Tactile Proprioceptive Vestibular Motor

Sensory Processing/Integration Disorder and DSM-V

Regulatory-Sensory Processing Disorders Treatment “top down” “bottom up”

Monitoring Percepts Top – down factors Emotion and Motivation Sensory input RAS Aleman and Laroi, 2008

Role of the Mental Health Clinician in SPD Primarily “top down” Normalizing Patient and family education Environmental interventions

Role of the Mental Health Clinician in SPD Compensatory strategies Self-esteem Planning for success experiences Treating comorbidities

Central Auditory Processing Disorder

Central Auditory Processing Disorder ,[object Object]

Auditory closure (fill in missing bits)

Auditory localisation(locate source of sound)

Auditory performance with degraded acousticsignal ,[object Object],background noise)

Central Auditory Processing Disorder CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors: sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder - Poor "communicator" (terse, telegraphic). - Memorizes poorly.- Hears better when watching the speaker. - Problems with rapid speech. - Interprets words too literally.

Central Auditory Processing Disorder - Often needs remarks repeated. - Difficulty sounding out words.- Confuses similar-sounding words.- Difficulty following directions in a series. - Speech developed late or unclearly.

(C)APD Treatment “top down” “bottom up” X

Treatment for CAPD Environmental modifications

Treatment for CAPD Compensatory Strategies strengthening higher order central resources (language, memory, attention)

Treatment for CAPD Compensatory Strategies Metalinguistic strategies include: schema induction, context-derived vocabulary building, phonological awareness, and semantic network expansion

Treatment for CAPD Compensatory Strategies Metacognitive strategies include self-instruction, cognitive problem solving, and assertiveness training x

Attention Deficit Hyperactivity Disorder

“I’m gonna eat all the gum and candy I want!”

Core symptoms Inattention / distractibility

Core symptoms Hyperactivity / impulsivity

….and the rest of the criteria Onset before age 7 Impairment in 2 or more settings Significant functional impairment Not better accounted for by another mental disorder

Functional impact of core symptoms Arousal / alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms Satisfaction control Previewing . Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD ADHD, predominantly inattentive type ADHD, predominantly hyperactive type ADHD, combined type ADHD, Not Otherwise Specifed

Common comorbidities with ADHD Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory processing challenges

ADHD and women More tasks More diffuse More parental responsibility Less likely to have an “executive” partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about disorganization

Executive Functioning:An Overarching Theme Sensory Processing Disorder Central Auditory Processing Disorder ADHD and Executive Dysfunction

The Executive Functions Internalizing speech Previewing Prioritizing Tempo control Inhibition

The Executive Functions Determining salience (what’s in it for me?) Blocking out distractions Self-monitoring and correcting Certain aspects of memory / learning

Age-appropriate expectations Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations K – 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules / inhibit / no grabbing

3rd – 5th Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even w/o teacher present Manners Simple delayed gratification (phone) Age-appropriate expectations

6th – 8th complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict Age-appropriate expectations

Teenage – mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say “no” to fun activity if other plans already made Take others’ perspective Age-appropriate expectations

“what is” vs. “what could be”

Introduction to Neuroanatomy Inter-connectedness of systems Cortico-striatal system, for example

Time Out Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Metacognition Metacognitiveknowledge Metacognitivestrategies

The Physiology of Motivation and Reward

Preferred States: What Does Dopamine Feel Like? Great experience Kodak moment The feeeeling

The Brain’s Reward and Planning System

The reward-and-planning system Anticipate goal Identify tasks Sequence / problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong Alicia R. Ruelaz, M.D.: “the biggest issue for me, and others I've seen, has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completed.”

Ways the reward-and-planning system can go wrong Jacy, a freelance artist from Connecticut,: I get so excited about a new idea, I forget the zeal that I had once felt for an old one. Thus creating my inevitable "idea graveyard.“

Ways the reward-and-planning system can go wrong Juzer :“my biggest problem is that I want to do everything all at once!”

Ways the reward-and-planning system can go wrong Inna: “I just get blank. I usually start sitting more slouched, hold my head with my left hand, ….you freeze and instead of being able to think of alternatives, you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to you.”

Ways the reward-and-planning system can go wrong Hank: “I have things I need to do to improve my marriage, my health and my financial situation, but I honestly believe that I have zero chance of actually making any of those three things actually get better. ”

Ways the reward-and-planning system can go wrong Alice, a oach from Long Island: The difference between a dream and a goal is a plan. It is the myriad of steps BETWEEN point A and point B that fail to happen. That is why a coach can be so important to folks with ADHD. A coach can help the person develop a step-by-step plan and help the person decide which steps they can & will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones).

Ways the reward-and-planning system can go wrong Anticipate goal (state) Identify tasks Sequence / problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong Anticipate goal (state) Working memory Insight Alexithymia / emotional intelligence Disconnect from values Diminished options Overly influenced by externals Too busy with current activity Field dependent

Ways the reward-and-planning system can go wrong Identify tasks Working memory Intelligence / development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong Sequence / problem-solve

Ways the reward-and-planning system can go wrong Sequence / problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong Sequence / problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves – in advance - how we want to invest it. - E. Goldberg

Ways the reward-and-planning system can go wrong Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong Get the reward

Ways the reward-and-planning system can go wrong Get the reward Satisfaction control Picked wrong task Picked wrong goal (“state”) Sociopathy

Instant gratification vs. executive gratification

PREFERRED STATES INVENTORY David D. Nowell, Ph.D. 189 May Street Worcester, Mass. 01602 DrNowell.com www.Lulu.com

Identify 20 peak experiences. For each peak experience, identify the highlight moment – the snapshot. Go to the visceral…what was the feeling of that moment? Name it. Check the 20 peak moment-feelings for clusters, groupings. There will probably be 4 or 5. PREFERRED STATES INVENTORY

Find a word, a label, for each of the groupings. Check for accuracy (“gut” check). Those are your preferred states, your “values,” ways that you really like to feel. Now you know your motivation…use this knowledge to review your daily activities and planning. PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Self-Talk Proficiency • -“How are you going to know when to be ready?” • -“How are you going to stop yourself from…?” • -“What is your goal?” • -“What do you want it to look like?” • -“How long do you think it will take?””

Self-Talk Proficiency • -“How are you going to know what you need?” • -“How are you going to know what is most important?” • -“How are you going to decide what to do first?” • -“How will you know when you are done?”

Self-Talk Proficiency • -“How will you continue when you are tired?” • -“How did that work out?” • -“How long do you think that took?” • -“Would you do anything differently?” “Who will be the first person to notice that….”

Executive Estimates Training X

Learning Time: What is the “felt” experience of time? What is the “frontal” aspect of time?

Learning Time: Theres no such thing as procrastination….there’s just choosing. And choosing again.

Asking two questions… Am I having fun now? And is this what I set out to do?

Am I having fun now? Is this what I set out to do?

Key Features of Video Games Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish inappropriate behavior – never reverse this

Key Features of Video Games Always follow up on rules, no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming focus groups to determine what really “grabs ‘em”

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human BrainVolkow, et al. 2004

Homework problems Fails to write down assignments Forgets the assignment book Forgets necessary materials Takes hours to do minutes of homework Hassles about when and where to do homework Lies about having done homework Needs constant supervision with homework Forgets to bring homework back to school

Homework challenges School / parent communication Routine Limit distractions Chunking Support the “getting started” Praise, reward, incentives

Your #1 Organizational Tool Yoga / read Phone calls Staff meeting Planning session billing

Your #1 Organizational Tool Vh: jeff w/ puritan oil Vc: kate re: brimfield TC umass dermatology. Spoke w/ cindy 508 8564000

Learn French Be a better spouse Stop smoking

The “Big Five” Daily focus time Values/motivational clarity Nutrition Movement Connection

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