Understanding and Supporting Clients with Attention Deficit Hyperactivity Disorder
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Slides for a presentation to vocational rehabilitation counselors with Massachusetts Rehabilitation Commission on 12/12/2014. This is a workshop I've presented to various audiences - including professionals, parents, and adults and their partners - for 1-hour to 3-hour to all-day trainings. Contact me to consider a similar workshop for your group at David@DrNowell.com.
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Understanding and Supporting Clients with Attention Deficit Hyperactivity Disorder
- 1. David D Nowell PhD www.DrNowell.com Understanding and Supporting Clients with Attention Deficit Hyperactivity Disorder
- 3. Overview • Brief definition of ADHD • ADHD evaluation and treatment • The “Big 5” • Ask 2 questions • Strategic behavioral inquiry (HËDŸDT) • Q & A & D
- 4. Overview • Brief definition of ADHD • ADHD evaluation and treatment • The “Big 5” • Ask 2 questions • Strategic behavioral inquiry (HËDŸDT) • Q & A & D
- 7. BRIEF DEFINITION OF ADHD
- 9. 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.
- 11. 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.
- 12. The Executive Functions • Making movies in your head • Talking to yourself • Being your own boss • Thinking and creating “what could be”
- 14. Preschool 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 14 1. 1-step errands 2. Chores with cues 3. Basic inhibition
- 15. Kindergarten - 2nd Grade 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 15 1. 2-3 step directions 2. 20-30 minute assignments 3. Follow rules/inhibit/no grabbing
- 16. 3rd-5th Grade 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 16 1. Simple shopping list 2. Keep track of variable daily schedule 3. Inhibit and regulate even without teacher present 4. Simple delayed gratification (phone)
- 17. 6th – 8th Grade 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 17 1. Complex chores 2. Organizing system 3. Time management 4. Self soothe 5. Manage conflict
- 18. Teenage-mid 20’s 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 18 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
- 19. Knock 3 years off his age
- 20. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 20 Lending Your Brain
- 22. ADHD and Brain Development
- 24. ADHD and Brain Imaging
- 27. ADHD Inattentive Hyperactive Combined
- 30. What are our data sources? • Record review • Interview • Collateral interview • Checklists • Mental status examination • Test scores
- 36. 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
- 37. Comprehensive ADHD Treatment • Medication – Stimulant – Non-stimulant – “Off-label” treatment
- 45. Two weeks from now, how will you know whether it’s working? Appendix C
- 46. Comprehensive ADHD Treatment • Behavioral Support
- 47. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 47 A ANTECEDENT B BEHAVIOR C CONSEQUENCES
- 48. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 48 A ANTECEDENTS B BEHAVIOR C CONSEQUENCES
- 49. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 49 A ANTECEDENTS Set them up for success
- 52. Meet with your ADHD employee for regular ongoing feedback
- 53. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 53 A ANTECEDENTS Identify exceptions Where do you see it the most? Where do you see it the least?
- 54. Rules •Waking up •Bedtime •Chores •Homework •TV / internet A ANTECEDENTS
- 60. Launching Pad
- 63. Communication •Get eye contact •Speak clearly •Provide behavioral info •Specific •In advance •Check for understanding A ANTECEDENTS
- 64. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 64 A ANTECEDENT B BEHAVIOR C CONSEQUENCES Behavioral Support
- 65. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 65 B BEHAVIOR “A healthy high-functioning 26 year old”
- 66. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 66
- 67. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 67 B BEHAVIOR More • Behavioral control • Choices and options • Self-regulation • Arousal • Motivation • Mood • Attention
- 68. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 68 A ANTECEDENT B BEHAVIOR C CONSEQUENCES
- 70. Determine what basic provisions are unconditional… • Love • Respect • Safety • 3 meals • Essential clothing • Temperature-controlled environment • 30 minutes of video games
- 71. …and which are contingent • Special foods • Expensive or trendy clothing • Extra video game time • WiFi password
- 72. Working Memory Training • CogMed • Lumosity
- 75. Movement Techniques • Exercise • Yoga • Martial arts
- 76. Turn 30 minutes into 45
- 77. Balance screen time and “green time”
- 80. The Caveman and the Angel • Creative visualization • Mindfulness • Neurofeedback
- 81. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 81
- 82. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 82
- 83. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 83
- 84. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 84
- 87. Mindfulness
- 88. Mindfulness
- 90. Supplements and Diet • Omegas • Food additives • Food allergies • Pesticides
- 91. 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
- 92. ADD Coaching
- 94. Comprehensive ADHD Treatment – May be expensive
- 95. The “Big Five” • Daily focus time • Nutrition • Movement • Sleep • Connection
- 97. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 97 …the most important 10 minutes of the day….
- 98. The “Big Five” • Daily focus time • Nutrition • Movement • Sleep • Connection
- 99. Barter Social/Practical Support • Food prep for optimal nutrition • Domestic organization • Pre-tax paperwork
- 100. The “Big Five” • Daily focus time / Motivational clarity • Nutrition • Movement • Sleep • Connection
- 101. “Exercise for focus” is different from "exercise for fitness”
- 102. The “Big Five” • Daily focus time / Motivational clarity • Nutrition • Movement • Sleep • Connection
- 103. Sleep hygiene • Strict bedtime • Use bed only for sleep • No caffeine after mid-afternoon • No activating media after 7pm
- 107. Fidget supports
- 108. Consider your own self-stim strategies • Applying lotion • Clicking pen • Sewing machine leg • Gum • Whistling
- 113. The “Big Five” • Daily focus time / Motivational clarity • Nutrition • Movement • Sleep • Connection
- 114. Marry well and get a crackerjack assistant at work
- 115. The ADHD Couple
- 116. Allow your non-ADHD partner or roommate to tackle longer-term projects: You take on more of the easy/quick tasks.
- 117. Don’t do anything for your ADHD partner or teenager which could just as easily be managed by a machine or an app
- 118. “Walk Me Up” app
- 119. ASK TWO QUESTIONS
- 120. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 120 Am I having fun now? Is this important?
- 121. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 121
- 122. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 122
- 123. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 123
- 125. What does dopamine feeeel like?
- 131. Yes Yes No Yes Yes No No No 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 131 Am I having fun now? Is this important?
- 132. Yes Yes No Yes Yes No No No Am I having fun now? Is this important? 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 132 I’m having fun. I’m on task.
- 134. Master these for awesome time management: • Appointments • To-do items • Habits
- 135. Yes Yes No Yes Yes No No No Am I having fun now? Is this important? 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 135 I’m having fun. I’m not on task.
- 136. Beware dopamine tricksters! • Facebook • Gambling • Shopping • Video games • Free online Aramaic course
- 137. There’s no such thing as procrastination • “There’s just choosing….and choosing again…”
- 142. Determine in Advance When You’ll Check Email and Facebook Tomorrow
- 143. StayOnTask app
- 144. Key features of a great planner system
- 145. Key features of a great planner system • 2 pages per day • Master to-do list • With the client at all times
- 146. Yoga / read Phone calls Staff meeting Planning session billing
- 148. Vh: jeff w/ puritan oil Vc: kate re: brimfield TC umass dermatology. Spoke w/ cindy 508 8564000
- 163. Key features of a great planner system • 2 pages per day • Master to-do list • With the client at all times
- 165. What’s a To-Do list for anyway?
- 170. Key features of a great planner system • 2 pages per day • Master to-do list • With the client at all times
- 171. Key features of a great planner system • The “technology” • The “practice”
- 172. Key features of a great planner system • The “technology” • The “practice”
- 173. Weekly Overview
- 181. Where will I most likely feel distracted today?
- 182. What will you do today that you'll still remember one year from now??
- 183. What are the activities you do NOT schedule? And why not?
- 184. Strategy to rule to habit 3. habit 2. rule 1. strategy
- 185. In review: • Appointments • To-do items • Habits
- 187. The “talking stick”
- 189. There’s no such thing as “disinhibited”
- 190. Yes Yes No Yes Yes No No No 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 190 I’m not having fun. I’m on task. Am I having fun now? Is this important?
- 191. Increase salience
- 193. Emphasize the sensory details of your desired outcome
- 196. If It’s Harder than a “3” Find Some Way to Make It Easier easy hard 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 196
- 198. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 198
- 199. Assign separate due dates for smaller parts of big projects
- 201. Use extrinsic reward creatively 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 201
- 202. Premack Principle
- 204. Time Horizon 1 hour 1 day 1 week 1 month 1 year
- 205. “Modified Independence” • Chronic disability perspective • Providing support at points of performance • Prosthetics
- 207. Reward small units of effort
- 215. Increase salience
- 216. Yes Yes No Yes Yes No No No 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 216 I’m not having fun. I’m not on task. Am I having fun now? Is this important?
- 219. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 219
- 220. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 220
- 226. Objectives of SBI • Specific behavioral strategy • What was the feeling-goal? • Motivational level on a scale from 1-10
- 227. Benefits of SBI • Affirms the value of clients’ unique internal experience • Emphasizes the culture of self-regulation • Encourages metacognition
- 228. 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
- 229. How to do SBI “How exactly did you do that?”
- 230. 12/10/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 230
- 231. Personal Application
- 233. …and How Exactly Did You Do That?
- 235. …and How Exactly Did You Do That?
- 236. Personal Application • What bad habit persists? And How Exactly Do You Do That?
- 237. 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?
- 238. Learn from your To-Do list • Which things are not getting completed? • How – exactly – are these not getting completed? How do you do that?
- 239. Clinical Application • Who in your caseload is demonstrating remarkable “resilience” – persistence despite significant obstacles? And how, exactly, does he/she do that?
- 240. 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?
- 241. 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? • Note: we aren’t asking “why did you do that,” but rather “how exactly did you do that.”
- 245. Let’s 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
- 246. MORE STRATEGIES THAT JUST MIGHT CHANGE YOUR LIFE
- 247. Tickler System
- 250. Take Advantage of Natural Systems • When do you know it’s time to toss veggies out of the fridge?
- 251. Create (Just Slightly) Unnatural Systems • Use a small in-box • Use a small magazine caddy • Schedule social events in your home
- 253. 60-Second Bathroom Cleaning Routine
Editor's Notes
- 5 MINUTE OVERVIEW
- 5 MINUTE OVERVIEW
- Sbi = at the end of the day you’ll be able to teach sbi. If yr teenager breaks curfew twice this month…sbi asks hedydt. If your 5 yo dtr gets in the car after a trip to the grocery store and says daddy did you see that funny lady…sbi asks hedydt. If your adult ct with adhd agrees that selecting a calendar and using a calendar on a daily basis…hedydt. Identify jargon buster
- Sbi = at the end of the day you’ll be able to teach sbi. If yr teenager breaks curfew twice this month…sbi asks hedydt. If your 5 yo dtr gets in the car after a trip to the grocery store and says daddy did you see that funny lady…sbi asks hedydt. If your adult ct with adhd agrees that selecting a calendar and using a calendar on a daily basis…hedydt. Identify jargon buster
- Certain aspects of memory / learning
- FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC. Preschool Run simple errands (e.g., “Get your shoes from the bedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks with reminders (e.g., clear dishes from table, brush teeth, get dressed). Inhibit behaviors: don’t touch a hot stove; don’t run into the street; don’t grab a toy from another child; don’t hit, bite, push, etc.
- FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC. Preschool Run simple errands (e.g., “Get your shoes from the bedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks with reminders (e.g., clear dishes from table, brush teeth, get dressed). Inhibit behaviors: don’t touch a hot stove; don’t run into the street; don’t grab a toy from another child; don’t hit, bite, push, etc.
- FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC. Preschool Run simple errands (e.g., “Get your shoes from the bedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks with reminders (e.g., clear dishes from table, brush teeth, get dressed). Inhibit behaviors: don’t touch a hot stove; don’t run into the street; don’t grab a toy from another child; don’t hit, bite, push, etc.
- FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC. Preschool Run simple errands (e.g., “Get your shoes from the bedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks with reminders (e.g., clear dishes from table, brush teeth, get dressed). Inhibit behaviors: don’t touch a hot stove; don’t run into the street; don’t grab a toy from another child; don’t hit, bite, push, etc.
- FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC. Preschool Run simple errands (e.g., “Get your shoes from the bedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks with reminders (e.g., clear dishes from table, brush teeth, get dressed). Inhibit behaviors: don’t touch a hot stove; don’t run into the street; don’t grab a toy from another child; don’t hit, bite, push, etc.
- Carrot and stick FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC. Preschool Run simple errands (e.g., “Get your shoes from the bedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks with reminders (e.g., clear dishes from table, brush teeth, get dressed). Inhibit behaviors: don’t touch a hot stove; don’t run into the street; don’t grab a toy from another child; don’t hit, bite, push, etc.
- Published in final edited form as: J Am Acad Child Adolesc Psychiatry. 2009 October; 48(10): 1014–1022. doi: 10.1097/CHI.0b013e3181b395c0 PMCID: PMC2891193 NIHMSID: NIHMS139337 Widespread Cortical Thinning Is a Robust Anatomical Marker for Attention Deficit / Hyperactivity Disorder (ADHD) Katherine L Narr, PhD, Roger P Woods, MD, James Lin, BA, John Kim, BA, Owen R Phillips, BS, Melissa Del'Homme, PhD, Rochelle Caplan, MD, Arthur W Toga, PhD, James T McCracken, MD, and Jennifer G Levitt, MD
- Comorbidities: anxiety, odd, LD, bipolar, and ?memory
- Record review / interview / mse / test results /
- Tobias, 58 y.o man with his son, 20 y.o. college student (psych). Son ? Adhd. Pt accountant, spvr of dept. 18 month h/o c/o re: inattention, poor focus after a reorg at work. Dx w dm um same t. Pt not compliant w b.s. checks or diet. St most helpful thing we can do is withhold a dx.
- Neuroanatomy Neurotransmitters Phenomenology of dopamine and serotonin
- Neuroanatomy Neurotransmitters Phenomenology of dopamine and serotonin
- Neuroanatomy Neurotransmitters Phenomenology of dopamine and serotonin
- Generally, humans prefer large to small, immediate to delayed, and guaranteed to uncertain rewards. However, as the delay preceding delivery of a larger reward increases, or the likelihood of receiving a larger reward decreases, the reward’s subjective value decreases. This decline results in a tendency to choose small immediate/certain rewards instead of larger delayed/uncertain rewards. Declines in subjective value attributable to the time of reward delivery are termed delay discounting. Declines that relate to the reward’s uncertainty are termed probability discounting. Pers Individ Dif. 2007 November; 43(7): 1886–1897. doi: 10.1016/j.paid.2007.06.016 PMCID: PMC2083651 NIHMSID: NIHMS33372 Adolescents’ performance on delay and probability discounting tasks: contributions of age, intelligence, executive functioning, and self-reported externalizing behavior Elizabeth A. Olson,* Catalina J. Hooper, Paul Collins, and Monica Luciana
- EXPLAIN WKSHOP’S PURPOSE, INCREASE SALIENCE, RELATE TO PRIOR K’LEDGE
- Get eye contact Speak clearly – avoid metacommunications Provide behavioral info Check for understanding
- CUTTING PLAY DOH WITH SCISSORS
- “this is your 1:00”
- Clarifying the 1st question Why is it important that our clients are engaged in commitments and obligations and relationships which are fun?
- Clarifying the 2nd question
- Clarifying the 1st question Why is it important that our clients are engaged in commitments and obligations and relationships which are fun?
- Emory University neuroscientists James Rilling and Gregory Berns. They found that the act of helping another person triggers activity in the caudate nucleus and anterior cingulate cortex regions of the brain, the parts involved in pleasure and reward. Ss instructed to plan 5 acts of kindness during week. Lyubomirsky, S., Sheldon, K. M., & Schkade, D. (2005). Pursuing happiness: The architecture of sustainable change. Review of General Psychology, 9, 111-131.
- Small group: id activities in each of 4 quadrants
- Google calendar w/ text f/u Supportive check-ins
- alarm
- Planner is with you at all times
- The technology and the px
- Body double Harder than a 3/10? Increase saliency: stimulant rx, “nothing tastes as good as thin feels” – brain cant tell the difference b/t real and imagined….but real is vivider, pairing dull/difficult tasks w/ intrinsic reward (e.g cape, med student)
- EXPLAIN WKSHOP’S PURPOSE, INCREASE SALIENCE, RELATE TO PRIOR K’LEDGE
- Can’t decide whether it’s important? Watch tv vs study french: make it vivid
- Getting to the gym – esp after full day’s work – is harder than a 3 / 10.
- 242”
- STUDY BOX
- GUESS HOW OLD?
- BELLY COUNTS FIDGET TOYS
- If only I could be as org. as I am the day before vacation
- EXPLAIN WKSHOP’S PURPOSE, INCREASE SALIENCE, RELATE TO PRIOR K’LEDGE
- Delete 30 FB friends Delete 3 “friends” Delete 2 commitments or obligations which arent fun or important (trauma survivor at txgiving; west boylston hxical society; I decided to stop eating foods that make me feel bad)
- With that background: understanding the executive challenge of asking – with each behavioral choice or commitment or obligation or relationship – is this task fun/rewarding, and is this task related to my core purposes? And understanding that the neurotransmitter of reward/fun shows up in our bodies in distinctive patterns we might call our “motivational blueprint,” we’re ready to do SBI.
- 29 times a month he made curfew. That’s great executive fx !
- I didn’t get my holiday shopping done.
- Which things aren’t getting done?
- MYSTERY BOX HAVE ST / VP PUT NAMES OF ATTENDEES IN HAT APPENDIX A p. a2: TO DO
- And don’t make it pretty
- Modern technology has evolved to exploit our urgency addiction: email, Facebook, Twitter, Quora and more will fight to distract you constantly. Fortunately, this is easily fixed: turn off all your notifications.Choose to check these things when you have time to be distracted – say, during a lunch break – and work through them together, saving time.
- Modern technology has evolved to exploit our urgency addiction: email, Facebook, Twitter, Quora and more will fight to distract you constantly. Fortunately, this is easily fixed: turn off all your notifications.Choose to check these things when you have time to be distracted – say, during a lunch break – and work through them together, saving time.