Episode 2: Training, Learning, & the ADHD Brain

Episode 2: Training, Learning, & the ADHD Brain

No doubt that the child who is late, disorganized, and scattered needs help. But are you lecturingpunishing, or giving zeros to that child in hopes that he will stop messing around and just get over it? On today’s Podcast, Dr. Russell Barkley will discuss ways to improve the brain’s Executive Function skills so that children can succeed in learning and life. He emphasizes that the most important premise in training is to help the ADHD student “perform” the strategies and not just ‘know’ them.

* This is Russ’s second podcast episode that discusses how to manage the needs of students with ADHD.

About Russell Barkley, Ph.D.

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Russell A. Barkley, Ph.D., is a Clinical Professor of Psychiatry at the Medical University of South Carolina. He is a Diplomate (board certified) in three specialties, Clinical Psychology (ABPP), Clinical Child and Adolescent Psychology, and Clinical Neuropsychology (ABCN,ABPP). Dr. Barkley is a clinical scientist, educator, and practitioner who has published 23 books, rating scales, and clinical manuals numbering 41 editions. He has also published more than 270 scientific articles and book chapters related to the nature, assessment, and treatment of ADHD and related disorders. He is the founder and Editor of the bimonthly clinical newsletter, The ADHD Report, now in its 25th year of publication. Dr. Barkley has presented more than 800 invited addresses internationally and appeared on nationally televised programs such as 60 Minutes, the Today Show, Good Morning America, CBS Sunday Morning, CNN, and many other programs on behalf of those with ADHD. He has received awards from the American Psychological Association, American Academy of Pediatrics, American Board of Professional Psychology, Association for the Advancement of Applied and Preventive Psychology, American Professional Society for ADHD and Related Disorders, New England Educational Institute, the Wisconsin Psychological Association, and Children and Adults with ADHD (CHADD) for his career accomplishments, contributions to research in ADHD, to clinical practice, and for the dissemination of science.

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No doubt that the child who is late & disorganized needs help. Find out how #FullPreFrontal Click To Tweet #RussellBarkley shares effective ways to manage needs of students with ADHD Click To Tweet

 

In case you missed it, here is the Part 1 Episode.

Transcript

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Todd Schnick: Alright, welcome back to Full PreFrontal. I am here with our host, Sucheta Kamath. Good morning, my friend. Kick us off. What’s in store today?

Sucheta Kamath: Here’s the story of Maddie and her transition from high school to college. Mr. Smith is a high school History teacher. He requires that his juniors keep a weekly journal in his class. Right after the midterms, it becomes apparent that Maddie’s class average has gone down from an A to B-, and the main reason for that is, for each weekly entry, her class journal barely has more than a few sentences in it. Her parents, of course, are outraged; they take the matters all the way to the principal. In their eyes, the B- would ruin Maddie’s chances of getting into the right college for her. After many, many meetings and even eventual big meetings, the mother intervenes and proceeds to tell Mr. Smith the reason Maddie is not doing her journal assignment, because she finds it boring, and after much considerations, principal, the learning support teacher, counselors, and Mr. Smith come to agree that they are going to let Maddie do extra assignment and turn it in, and her class average will go up from an A to a B—Maddie’s class average will go up from a B to an A. After several many meetings and eventually a big meeting, the mother intercepts and talks to the counselors, advisors, learning specialist, teachers, and principal together, and proceeds to tell Mr. Smith that Maddie is not writing in her journal primarily because she finds that exercise boring. And as you can imagine, with this forceful beast called ‘Mom,’ the teacher gives up and special accommodations or adjustments are made and Maddie is allowed to bring her class average from a B- to an A.

So one would think the story ends there but no, let’s fast forward. Now, Maddie is a sophomore in college. One fabulous fall Sunday afternoon, Maddie’s laptop freezes. She could have easily taken to a few people on her floor who are tech-savvy. She could have called Apple Support. She could have even reached out to the IT guys that are permanently stationed in the student center, but no. She doesn’t do any of that. Instead, she calls her mother who literally is on the opposite coast, and when she calls, she obviously is in panic, and which makes her mom get in a panic, and the mother proceeds to call the manufacturing, the laptop manufacturers. She calls the TA for which Maddie is preparing a paper and asked for an extension.

So the question is, what went wrong here? What I find that, executive dysfunction looks like this: it starts with student’s inability to understand the importance and value of a simple task such as write a journal entry, and when the student fails to understand the importance and value, she doesn’t comply with it. When she doesn’t comply with it, the parents who are generally relying on good understanding of the student’s understanding of the assignment and hope that she would complete the assignment with prodding and coaching. And when she doesn’t do that, they are left to take a step, and in Maddie’s case, Maddie’s mother just turned out to be a terror; she went all the way up the ranking and she maneuvered, and manipulated, and intercepted to help success happen. But what we do know, that that success is short-lasting because what Maddie failed to learn is how to make herself do: how to make things happen for herself by taking care of her goals, taking care of actions, organizing herself, and solving problems for herself, and executive dysfunction or executive function disorder looks something like that. So Maddie may not actually have a diagnosis of executive dysfunction, people who don’t understand executive function disorder or dysfunction may call it simply, Maddie is either lazy or Maddie is difficult, or Maddie’s parents may feel helpless and helped Maddie to become successful with as much support and coaching as they can, and student and teachers, TAS, and professors, and observers may find this kind of support unnecessary or outrageously over the top, but eventually, who is suffering? It’s the student and her growth.

So this is the topic of our discussion. We are going to talk with Dr. Russell Barkley and his incredible insight into how to support and help students who have these kinds of challenges which makes their success outside classroom a big challenge.

Todd: Lots of students are going to benefit from this conversation as well as their parents. I’m looking forward to it, let’s get to it.

Here is Sucheta’s conversation with Dr. Russell Barkley.

Sucheta: Our guest today is an internationally-recognized authority on the subject of ADHD. Dr. Russell Barkley is a clinical professor of psychiatry at the Virginia Treatment Center for Children, and the Virginia Commonwealth University Medical Center in Richmond, Virginia. He has published 23 books; many of them have been bestsellers, rating scales, and clinical manuals, and 270 scientific articles and books’ chapters related to the nature, assessment, and treatment of ADHD and related disorders. Dr. Barkley is the founder and editor of the bi-monthly clinical newsletter The ADHD Report, now in its 25th year of publication.

Dr. Barkley has presented more than 800 invited addresses internationally and has appeared on nationally televised programs such as 60 Minutes, The Today Show, Good Morning America, and CBS Sunday Morning. He has created seven professional video tapes on ADHD and Defiant Children, three of which have won national awards including the 1992 and 1994 Golden Apple Award for educational video from the National Education Association. Dr. Barkley has received numerous awards over his career and his work in ADHD and the field of psychology. In 2002, he received the Dissemination Award from the Society for a Science of Clinical Psychology, division 12 of the American Psychological Association for his career-long effort to dispel misconceptions about ADHD and to educate the public and other professionals about the science of this disorder. In 2012, Dr. Barkley was given the Distinguished Career Award from the Division of Clinical Child and Adolescent Psychology of the American Psychological Associations.

Personally, Dr. Barkley’s work has had a significant impact on my understanding of development of prefrontal system and the disorder of ADHD.

Welcome to the show, Russ. It’s such an honor to have you and thank you for doing this part two to our previous discussion where we spent time discussing what exactly is executive function. So I encourage all our listeners to go back and listen to Russ’ previous interview.

I wanted to dive into the topic today of how to manage executive function disorder. So could you help our listeners understand executive, do we call it executive dysfunction? Do we call it executive function disorder? And how does it relate to ADHD, and how do we understand the diagnosis of this so we can treat it?

Dr. Russell Barkley: Great questions. As we discussed in the first part of this podcast, there was an effort to define executive functioning there as self-control. What are you doing to regulate your behavior? And there are seven things that people do mentally to try to manage themselves in order to get to their goals, improve their future, and look after their welfare. And we talked about self-awareness, inhibition, visual imagery, talking to yourself: your mind’s voice, the ability to manage your emotions, self-motivation, and planning and problem-solving are the major executive abilities, and we also talked about the fact that although we use these together in sort of a symphonic arrangement and orchestrate them, but the fact is, they are separable and you can have a deficit or an impairment in one or all of them, and all of those would be considered an executive function disorder or deficit. And we would call it a disorder if it reached a point where it was leading to harm or impairment in functioning in the environment. So you can be impaired in one, two, three, or all seven.

Now, when it comes to ADHD, Attention Deficit Hyperactivity Disorder, we think of ADHD as an executive disorder or at least I do because what makes it unique is it interferes to various degrees with all seven of these executive functions, whereas other disorders, like autism or bipolar disorder, or even brain injury if it’s frontal brain injury or localized, may interfere with a late one or two of these and not all of them, but ADHD is a pervasive disorder of the brain’s executive self-regulating system. Essentially, the prefrontal part of the brain.

Sucheta: Got it. So help us understand, you always recommend that don’t focus too much on skills training or rather don’t put all your baskets in skills training, all your eggs in skills training basket, and you definitely encourage everybody to think about symptom reduction with the focus on preventing secondary harm. Can you tell us why you consider those factors important for managing executive function disorder?

Dr. Barkley: I do, because I think if you don’t go back to these very basic ideas about what is executive functioning, you will choose the wrong strategies to try to ameliorate or rehabilitate the deficits. So I teach it this way, even to laypeople: you can divide the brain into two pieces. The back part of the brain is where you learn knowledge and skills, and store it. The front part of the brain is where you apply that knowledge in daily social effective performance. So the back part is knowledge, the front part is performance. The back part is knowing, the front part is doing. It’s where the knowledge meets the road. It’s where you apply what you know to be a more effective individual to look after your own welfare, and so if you don’t understand this difference, you may go down the road of trying to train people with executive deficits in skills and knowledge. You’ll approach them as if they’re stupid, as if they’re ignorant, as if they don’t know what they’re doing, and, “If I will just show them how to do this, like I’ll show them how to do time management, I’ll show them how to organize their workspace, and having shared my deep knowledge of these strategies with them, I have solved the problem because now, they’re no longer ignorant and they could go on their merry way and use the knowledge I had given them.” But you would be sadly mistaken and you would fail because the problem that people with executive deficits have is not in knowing what to do; it’s in using what they know. It’s in the doing of those strategies. So I can teach you time management but you won’t do time management, and that means then that in order to help someone with an executive disorder, you can’t just review the skills to make sure they have them. I’m not saying not to do that; I’m just saying you might want to spend only 20% of your involvement in skill review. The other 80% needs to be redesigning the environment to help probe them to use those strategies in the environment at the point of performance where it would be wise to do so, where it would be more effective to do so. So we want to help them perform the strategy and not just know the strategy, and yet, most mental health professionals and rehabilitation people get caught up in the knowledge training, the knowledge transfer, the cognitive rehabilitation, and don’t spend enough time on the generalization, on the performance side in the natural environment where these strategies need to be used. And if you don’t put it there, these people aren’t going to use that strategy at all and you will have failed. But you’ll be blaming them for the failure because after all, you did what you thought was your job; you taught them the knowledge and if they don’t want to do it, well, that’s their problem. They must have some motivational problem or they’re just not committed to change, or you come up with some other flimsy information.

Sucheta: Or they are difficult people.

Dr. Barkley: Yeah, or they’re difficult people, so you blame the victim for their inability to use the skills you gave them when the fault is yours.

Sucheta: I have found two essential processes that really can circumvent that. Number one is, experiential training. That means allow the patient or client, or student to experience the process of application skills in the context, or artificially creating context where they actually would need to adapt their learning, so not teaching the learning, and making a lecture-based learning, or as we said, transfer of knowledge. And the second part, I have found it very effective is error analysis training. That means looking at errors of somebody else, either the videos or recordings of somebody, or actually, paper-pencil errors and evaluating errors from a perspective of somebody else. And I have found those two tools really strongly helpful for these ADHD population. What do you think about that sort of training?

Dr. Barkley: I think those are great ideas because first of all, you’re looking at self-monitoring. I mean, video self-modeling is now being used with autistic children and I think it should be used with ADHD individuals as well because it’s improvement in self-awareness, and so it doesn’t have to be just watching others; you can actually video the person as they perform and then review that video as well. The only thing I would add to that would be to make sure you pay attention to generalizing from the training environment to the real ecology of their life, and that simply, may be, putting little prompts or cues, or other little signs or sticky notes, or something around them out there that simply prompts them to remember what you were working on with them in your training session. So I think that that’s wonderful. I would just add that next step of, how do I program the generalization of the training and strategies that I’m doing?

Sucheta: What I have found effective for that transfer and generalization is a very meta-cognitive training, awareness-based training where you keep data on yourself. So I have developed a very detailed planning process, planning tool, that acts as a data-keeping tool where the goals are created for self and then during the day, the client is recommended to review the goals for self, and then have some type of tally, like Benjamin Franklin used to call End of the Day Learning, EOD, I think, and having the patients do that or clients do that, at the end of the day, kind of take an inventory. This habit, again, as you know, many people do not have, so even kind of prompting them to inculcate this habit and creating either video prompt for self or audio recording of self to be transferred or submitted through website that I have created really, really helps.

Dr. Barkley: Yes, you have to do it over and over, and over again in order to instill it into the automatic brain, but another distinction that people fail to make, and it’s an important one, we talked about the back part of the brain is knowledge, the front part of the brain is performance, but we also need to make the distinction that Daniel Kahneman made in his bestselling book two years ago, Thinking, Fast and Slow, that the executive brain is the slow brain; it’s where we use our strategies to learn new ways of doing things. So it’s the novel part of the brain, and the rest of the brain is the automatic brain. It’s where we do things without even thinking because we’ve overlearned them. And following this way of thinking about executive function, it’s very important that people, when they practice these executive strategies, practice them over and over, and over, and over again, so that they move from the executive effortful brain down into the lower automatic brain, and outside necessarily of that kind of consciousness: you just automatically do that in a situation. And that’s how we learn anyway but I think what you’re doing here is very important, that getting them to practice, practice, practice in that natural environment using these strategies, they are at that point of performance, and then the more they do that, the more likely it is to be embedded into the automatic part of the brain instead of the thoughtful executive brain having to come online all the time and do this.

Sucheta: And what I find, Russ, as you pointed out earlier, that motivation to make change. Change, first of all, as you understand is painful, and then if the change that needs to be made with the context of human mind is even more painful, so what is the motivation to change yourself for those who have motivational deficit disorder? Can you help us understand a little bit about how the motivational wires are connected to executive functions?

Dr. Barkley: Sure. Sure. Well, first of all, we use a variety of our executive functions to motivate ourselves. So we use imagery: we visualize the goal, we visualize the reward, and that image in our mind often activates our brain’s reward and motivational centers. We also talk to ourselves. We also give our self encouragement, like a little locker room pep talk from a coach, and we say things to ourselves to enhance these images about our mastery: our self-efficacy, our ability to achieve that goal that we are trying to achieve, and we may describe the pleasure that we’re going to experience when we get to the goal and we receive whatever the rewards are that we are seeking through performing that goal. So there are various ways that we use images and words directed at ourselves in order to motivate ourselves in situations where there’s no external consequence for getting the work done, and by the way, that’s about 80% of life, is having to get things done where the consequences are quite delayed, and yet we have to do those things now. So visual imagery and self-speech are great self-motivational tools for trying to develop this. You can also supplement them with pictures of the goal and the reward, if you put outside of you. Just like people try to lose weight, they might take the image of their younger self back when they didn’t have so much weight as a goal to achieve, or clip a picture of a supermodel out of a magazine, maybe, and put that on the refrigerator, but we all may put little things around us in order to motivate us to do that. Another way is agreeing to do something with another person. So exercise is a good example of that. If you want to start exercising and you want to use running, for instance, as you’re exercising method, then maybe you should find somebody to run with at a certain time of day because we’re much more likely to motivate ourselves to engage in that self-change, that exercise, in this case, when we make ourselves publicly accountable to another; we’ve made a commitment to another person, so using others for social commitments is a great self-motivational tool to help us change things that are hard to change, and there are a variety of these other strategies but they’re all ways of using the environment around us to try to motivate ourselves to get to our goals.

Now, some people aren’t necessary ready for that sort of change, and Prochaska talked about, in his work on his model of readiness to change, that there are several stages that people move through in trying to change themselves, and it’s helpful for people, particularly for you and I working with clients, to identify at what stage of readiness are they because what we’re going to do for them is going to differ markedly based upon what stage they’re in of wanting to change. If they’re in the precontemplation stage, then they haven’t even recognized that they need to change, and we might need directing information about their ADHD or their executive disorder and its harmful consequences, and what has happened to them already that in order to move them from precontemplative into contemplating change, and so on. We don’t have time here to go into Prochaska’s model but if I can just direct you to my most recent book that came out this past fall which is When An Adult You Love Has ADHD, and we’ve made the readiness to change model of Prochaska the centerpiece of this book in order to guide loved ones of how do you help somebody with ADHD? And the first thing you have to do is know where they are and start where they are, not where you are—where they are, and so we go through the five stages of change, and then teaching them the different things you would do based on where your loved one is in this sequence of self-change. And so I would direct people to that book as a great place to start if you’re dealing with adults. Now, of course, if you’re dealing with children, then my book Taking Charge of ADHD might be better for that.

So let’s just say that you have somebody who’s ready to change; they’re committed to change. Now, what are the six things that you must do to help somebody with an executive function disorder, whether it’s ADHD or one of the more focal disorders, what do you have to do? The first thing that you have to do is you have to prompt them in self-awareness. You have to do the things that you were talking about. You may need to set up cues that trigger them to self self-monitor. It may be something they’ve put in the environment, in a place where they don’t often monitor what they’re saying or doing. It may be having another person around them cue them, like putting a finger to their lip in order to caution the individual or simply giving them a particular facial expression that only the two of you know is the cue to stop and think about what you’re doing here. You seem to be getting a little away from yourself. I don’t think you are aware of how you’re coming across, but just some little cue that could prompt them to self-monitor what they’re doing.

Sucheta: If I can jump in and share one quick story which you might enjoy, so in my work with clients, I prepare something called Letter From Future Self, and I video record the students or client reading, even adults, reading these letters coming from a year, our future self, thanking the current self for all the changes he has made, and we take a picture of that sign, I have created a sign, and I send the video to the clients, as well as I take a picture and ask them to stick that picture at their work desk, and so this connection to future self, and I base a lot of my work based on Hal Hershfield’s research on future self and the temporal discounting that we do, and I find that has been added, again, based on your model of visual imagery and concretizing this notion of passage of time to achieve a better outcome for that distant me—oh, wait a minute, that is me, and developing some emotional relationship with that future self.

Dr. Barkley: I think that’s actually brilliant. That’s a great way of exemplifying this concept of self-awareness. It’s not just about being aware of who you are now, what you’re being aware of is who you are now relative to where you want to be, otherwise, there’s no need for self-awareness. So self-awareness is always this, juxtaposing the current me to the future me I want to be, and that’s why we have self-awareness. So that’s a brilliant strategy for trying to get them to think about the two needs: the now me and the future me, and then what do I need to be doing now to get to that future me? So what a great strategy.

Well, so that’s one thing that people can do. The second thing then is the executive system is where we hold information in mind that is guiding us, both visual information and self-speech or verbal information, but it’s very weak in people with executive deficits. Working memory isn’t working very well, and so what I tell people is to offload that memory. That’s the technical term but get that information out of your brain, out of your mind, on to things around you as reminders of what it is you are trying to do, a do list, for instance, is a very good example of offloading your working memory onto a sheet of paper with a set of goals that you want to accomplish, or with a set of steps that you’re trying to follow in this immediate project that you’re doing, and then the external information can then make up for your working memory. Carrying a journal around with you, a very low-tech solution where you write down what you agree to do for others, or what they’ve asked you to do or what your goals are today, and then referring to that journal in your pocket frequently throughout the day is another way of offloading working memory out of the defective working memory brain and onto some other technology, some other recording or storage system, and there are many, many ways to do this, from digital memory recording devices to, as I said, low-tech, I think, is even better: just sheets of paper, calendars, journals, week-at-a-glance events, project accomplishment things that you can find in these day planners. They’re all simply ways of offloading your working memory in order to better control yourself, so that’s the second thing you have to do.

The third thing you have to do is make time real; make it physical because people with executive deficits, especially ADHD people have very serious problems with time and time management, and so having external clocks or timing devices around you when there’s a time limit for getting things done is another strategy. In other words, again, you’re offloading time out of the brain onto an external device of some kind that’s going to show you your time and your goal.

And then, of course, we talk about learning to alter your emotions by using your executive functions so that you learn better emotional self-regulation. Cognitive behavioral therapy, by the way, is exactly that; it’s where we teach people how to use their self-speech and their imagery to alter these emotions that they find so troubling, or to improve just their emotional self-regulation.

And then we talk about, how do I self motivate? Well, I create consequences for my work. I create artificial consequences. I make a promise to somebody that, “If I accomplish this goal, you and I will go to Starbucks, or if I accomplish this goal, I’ll allow myself that reward,” and we put ourselves on these little self-reward programs in order to further our motivations.

So there’s a variety of things we do or can do to address each of these executive deficits. But as you pointed out in the beginning, there is a limit to this executive system. You need to think of it as a fuel tank that can be exhausted in your car, and we need to periodically be aware that we can sometimes overtax the executive system and we need to give it a rest once in a while, especially when we’re involved in extended projects, because the more we draw on it, the more we run out of fuel, and then we fail. We don’t have the self-control we had originally. So there’s a variety of strategies people can use to try to do that. One is to work for a short time, take a break, work, break, so that you break up the work into smaller chunks with frequent breaks. The second is exercise. The third is using visual imagery and other devices to think about your goals and give yourself these pep talks. The fourth one is meditation, and the final one is making sure that you have had adequate nutrition, particularly little bits of glucose in your diet while you’re working. I’m not talking about swallowing a 32-ounce Gatorade; we’re talking about sipping on sports drink or other sugar-containing substances just to make sure that you keep your blood glucose because your frontal lobe runs on glucose, and if you’re getting low in your nutrition, that can also cause you to fail in your—

Sucheta: That’s the fuel for the brain.

Dr. Barkley: Yes.

Sucheta: Wonderful. Well, I cannot imagine we’re at the tail end of our conversation here. You have been incredible in sharing the wealth of your knowledge, and our listeners are going to be probably needing to listen to it couple of times so they can understand and retain all the suggestions you have made.

Before I let you go, Russ, should anyone have any questions or want to learn more about your work, where do they go?

Dr. Barkley: My website is the best place to start which is russellbarkley.org, and you’ll find lots of information, free fact sheets on executive functioning, my books, and links to other websites that are useful, and so on. And then I have a second website in which I posted about 35 hours of free lectures for viewing, and that is ADHDlecturers.com, and then of course, many universities have posted my lectures onto YouTube, so if you went there and just searched for my name, my lectures would come up as well.

Sucheta: Thank you, Russ, for making the time to join me on my podcast today.

Dr. Barkley: It’s been a pleasure. Thank you so much.

Todd: Alright, Sucheta, another terrific conversation with Dr. Russell Barkley. Wow, great stuff. He let us off by talking about some of the ways of treating ADHD and executive function disorder. What are your thoughts on that?

Sucheta: Yeah, you remember, in his first interview that we did with him, he described executive functions as your ability to control yourself: what you think, what you say, what you do to get to your goals, and he described these seven major executive abilities, and I’m going to review that because these are the ones that everybody can relate to as he talks about strategies. So the first one is self-awareness. The second one is impulse control. The third one is using visual imagery. Fourth one is self-speech or self-talk. Fifth one is emotional self-control or emotional management. Sixth one is self motivation, and the last one is planning and problem-solving. Either one or a few, or all of them can be impaired. ADHD is an executive functioning disorder particularly because all seven executive functions are impaired in it. It causes a problem with self-regulation. Now, when I say all seven are impaired, Dr. Barkley was referring that as, in certain amount or certain capacity, and just depending on what area is weakest of all or less evident, the symptoms will vary. On the other hand, he said that neurological disorders, like autism or bipolar, or OCD or obsessive-compulsive disorder, or TBI which is traumatic brain injury, are some of the disorders where executive components may be problematic, but ADHD is a singular disorder where all seven components are definitely impaired. So treating ADHD then means addressing all seven basic abilities.

Todd: Russ also did, I think, an important job of connecting the functions of the prefrontal cortex and executive function. Any strategies there or any takeaways we should be aware of with this?

Sucheta: Yeah, here’s the first to take away. Everyone needs to understand the basic difference between the prefrontal cortex and the rest of the brain. The back of the brain is where you store knowledge. That’s what knowing means or is stored. It’s more an automatic brain. It stores habits. Once learned and they are practiced, these skills become old and automated. The prefrontal cortex, which is the front part of the brain, which handles the novel stuff, is the slow brain. It’s where knowledge meets the real world, as Russell said, that we use this brain to navigate unfamiliar situations where we have no prior information, and that’s where we adapt and adjust. So the best way to treat disorders of prefrontal cortex is to train the brain to handle novelty by applying knowledge. Repetition is an important key in that and one must practice habits of mind over and over again to succeed and compensate for executive function problems.

Todd: Yeah, reflecting on that conversation that you had with Russ, you shared so many helpful ideas. Any other takeaways we should be aware of?

Sucheta: Yeah. So here’s the second takeaway from Russ’ talk. If you understand executive functions, then you’ll be able to treat it with that in mind. A common mistake, he said people make, is when helping kids or adults with executive function problems, they often talk about the skills that are lacking, so they use talking as an avenue to, so to speak, wake the patient up or wake the client up, or even lecture them about the strategies. For example, “Why didn’t you make a plan? Why don’t you use a timer?” This kind of conversation, he calls it ‘knowledge training,’ and he was emphatic that that doesn’t work. What really helps is performing those strategies or implementing them by using them in ways that gives the kids or adults the experience of developing the missing skills. And another important point he emphasized, that implementing them in the context where they’re used, so if you’re talking about doing homework, telling the kid in the classroom when he has a one-on-one time with the teacher or when he is meeting with the learning specialist in her office, or somebody who comes to my office, they are not doing homework in these spaces, and so sometimes, the strategies don’t get transferred until and unless those who are teaching these strategies create or mimic that home environment or teach the strategies in the context of the home environment.

Todd: Well, you too, also talked about motivation and how that can really be a big problem for many with executive function disorder. Dr. Barkley had several ideas to help with that. Walk us through some of those.

Sucheta: Certainly. In his third takeaway point, Russ talked about how we use a variety of executive functions to motivate ourselves. We direct images and words towards our self to get to our goals. We use visualization. We imagine the rewards for our hard work and our success. Sometimes, that can be hard so we use actual images or pictures to self-motivate. It’s that picture of that polka dotted bikini that is hanging on your dresser mirror when it’s November so you’re thinking about the summer and you’re working, and the days you don’t feel motivated or feel like going to exercise, you’re using that actual picture of the polka dotted bikini to say, “I must go to the gym.”

Secondly, we do self-talk. We use self talk as a tool. We are preferably capable of giving ourselves a pep talk, like a little coach, internal coach, and some encouragement we are able to offer, and he talked about that. And we also have the capacity to talk to ourselves about our self-efficacy and self-mastery, and these kinds of conversations directed towards inside self can act as a motivational kind of bump, so to speak. As you can see, teaching visualization and self-talk are fundamentally essential for motivational management in ADHD as Russ points out.

Todd: Well, I’m also thinking about self-awareness, and Russ did talk about how self-awareness can be improved with self prompting. Walk us through that.

Sucheta: Oh, absolutely. His fourth takeaway was to create prompts or cues for yourself and, for example, he talked about distributing prompts, which is like either little stickies or reminders, or pictures or laminated sheets in environment where you are working or the space where you live, this can really help in self-monitoring. That means, “What am I supposed to do? Oh, wait, this is a clue,” And, “Am I doing it? Wait, oh, I’m not doing it.” So this kind of conversation can be had with those prompts that you have created to jog your memory. This also, he pointed out, that frees up mental space. So lots of thoughts about things that I need to take with me when I leave the house and if I am holding onto them in my head, that I need to take a, like I did, a newly purchased microphone that came to the house or I need to carry my lunch, or I need to take a gift card because after my office, I’m going to go shopping, so instead of having to hold onto all those things in your head, he recommended to either journal them or to create a do list, and these kinds of tools really, after repeated prompting, can improve your self-awareness and then it can eventually affect your outcomes and impact your future self.

Todd: Yeah. I know. That was a fascinating part of the discussion. Alright, so Sucheta, any final thoughts? Any conclusions from this conversation with Dr. Barkley?

Sucheta: Oh, yes, I truly feel the love he has for ADHD population and the service he has committed too. And what I gathered from this conversation is, don’t treat people with ADHD as if they are incapable or stupid. Just because they are disorganized or late, or don’t remember to turn homework in, doesn’t mean that they cannot do the work. Resist the temptation to want to tell them what to do, like, “Why don’t you organize your binder? Why don’t you set an alarm? Why don’t you write it down next time?” Instead, what really will help is practicing writing it or practicing setting the alarm, practicing the process of organizing the binder. So the ADHD person is not doing the most essential training principle which is doing and experiencing rather than hearing and listening, and understanding what needs to be done.

There are a few more things that will strengthen executive functions. With effortful work and as the day progresses over time, self-control depletes. It just goes down for any average brain, and he had some interesting and simple ideas that can boost the self-control, and the first one that he said was exercise. Second, he said meditate. Third, he said sip on sugary liquids. You don’t have to guzzle down the whole can of soda but even taking a few quick sips can boost the frontal lobe energy and bring it on, and make it completely woken up.

So all in all, I think executive functions can be managed, and what a great optimistic way of leaving us with his wisdom about executive function management.

Todd: I could not agree with you more. Very powerful and very important conversation with Dr. Barkley. So alright, it’s all the time we have for today. On behalf of our host, Sucheta, and all of us at Cerebral Matters, thanks again for listening and we look forward to seeing you next week on Full PreFrontal.

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Sucheta Kamath
Executive Function Specialist at Cerebral Matters
Sucheta Kamath, founder of private practice (Cerebral Matters), is an expert in brain training & Executive Function development. She is a TEDx speaker and a recent graduate of the Leadership Atlanta class of 2015. Sucheta will be launching ExQ, an educational software company that offers accessible, web-based learning management tools for all in Fall of 2017.

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