ADHD
TREATMENT
ANDREW J. RÓZSA, PhD, PsyD
PREAMBLE
THE WINGS OF A BUTTERFLY
BUTTERFLY EFFECT
The fluttering of the wings of a butterfly
in one part of the world is seen to
contribute to the causation of a tornado
in another. In a complex, dynamic
system, over time a small cause has
large consequences
THE CHALLENGE
Today’s session will challenge
many of your concepts in the
treatment of mental and
behavioral health disorders.
Today I will challenge your
concepts of:
1. Diagnostics
2. Treatment
3. Your contribution
OUTRAGEOUS STATEMENT NO.1
What does this have to do with ADHD?
• It turns out that ADHD is absolutely the best starting point for
the conceptualization of ALL other mental health and
behavioral issues. Furthermore, ADHD is the cause to the vast
majority of “problems” you will be seeing in your practice.
• It makes no difference whether you work with substance
abusers, fosters, adoptees, academic failures, behavioral
disasters, conduct disorders, autism, busted marriages, cutting,
suicidal ideation, depression, anxiety, …. underlying them all is
some aspect of ADHD.
A REALLY OUTRAGEOUS STATEMENT
Outrageous statement, you say?
Not if we redefine
Attention Deficit Hyperactive Disorder
THE PROBLEM: WHAT’S OUR JOB?
We are Psychologists, Professional Counselors,
Clinical Social Workers, or some other type of
Mental Health Professionals.
What’s our JOB when we meet our youth (and
adults) with ADHD?
• As I stated last month, ADHD plus comorbidities
are inevitable and by far the most pervasive
mental/behavioral health condition underlining most
visits to our services.
• Let me remind you what I am talking about:
“NORMAL”
School is designed for kids in
the middle of the bell
curve. The most successful
students are those who fall
into the normal range in the
two areas school rewards
most – math and language.
They are the ones who get
called smart and get to think
of themselves as smart
NOT ROUND PEGS
As I tell the parents of my patients, imagine the
educational system as having standardized everything to
fit into a round hole. So, EVERYBODY has to fit into the
round hole in order to be successful. What we are
rewarding is the state of being a “round peg.” Vanilla.
Average. Within two standard deviation around the mean.
And here comes your child. She is not a round peg. She
is some other shape. We don’t even know WHAT shape
she is. But the law (IDEA) states clearly: every child has
the right to a free appropriate public education (FAPE).
Now our kid here is NOT plain vanilla. He is some other
flavor. AND he has got sprinkles. And swirls.
UNCOOL
Now what?
In the past, schools tried to hammer
everybody into the “round hole.” If they
didn’t fit we called them morons,
minimally brain damaged (an old term
for ADHD), hysterical, funny looking,
crazy, a psychopath, withdrawn from
reality, etc.
How uncool, right?
DIAGNOSIS
• DSM-5 is not a true nosology - forgets about the social embeddedness of
all behavioral health conditions.
• The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) claims
that it improved on the previous version by incorporating a “greater cultural
sensitivity.” Really? It sure appears ethnocentric to me and views culture as
static, the diagnostic criteria may or my not be valid, for a specific frozen
image in time. The current trends in psychiatric nosology emphasizes
neurobiology and decontextualizes distress. As if distress occurs in vacuum.
According to the DSMs of yore and present, sociocultural context is relevant
only for some patients.
You and I MUST think of behaviors within their social context.
BIOPSYCHOSOCIAL CONTEXT
Here is a photo of my son at age 4.
Made my mother-in-law choke on her grits when she saw it.
The rain was warm, the kid has Asperger’s (still learning
about social rules), ADHD (zero impulse control), and
Sensory Processing Disorder - hated the idea of wet clothes
touching his skin, but he wanted to bike now (perseverance,
inability to postpone gratification).
What should I have done about it? I took a picture while
howling with laughter.
Biopsychosocial entity in context!
PHENOTYPE
• We have analyzed the etiology, the genetics, the neurobiology,
the neurochemistry, environmental factors, and the phenotypic
expression in young people with ADHD.
• The phenotype is the set of observable characteristics or traits
of an organism. The term covers the organism's morphology or
physical form and structure, its developmental processes, its
biochemical and physiological properties, its behavior, and the
products of behavior. The term covers the organism's
morphology or physical form and structure, its developmental
processes, its biochemical and physiological properties, its
behavior, and the products of behavior. Phenotypic expression
is the result of a complex interplay between an organism's genes
(genotype) and its environment.
In other words, scientifically speaking, what we see when we
meet one of our clients is the phenotypical expression of all the
issues we covered previously.
NEURODIVERSITY
It is important for us understand that what you and see is the
combination of an almost infinite number of variables which result in
an infinite number of … client varieties.
• Neurodiversity is the range of differences in brain function and behavioral traits.
Neurocognitive variation and differences can include individuals with autism, attention
deficit hyperactivity disorder (ADHD), dyslexia, Tourette’s syndrome, anxiety, obsessivecompulsive disorder, depression, intellectual disability, and schizophrenia, as well as
“typical” neurocognitive functioning. Neurodivergent individuals are those whose brain
functions differ from those who are neurologically typical, or neurotypical.
STILL NEURODIVERGENCE
• To be sure, diagnostic labels ARE useful, in fact, they are
necessary. It’s how we interface with the neurotypical world. It’s
how kids get absolutely necessary services and
accommodations. They can also be useful communication
“devices.” When my wife says “that’s an Aspie thing” that’s a
signal for acceptance.
• But, at the intrapersonal level, I prefer to view myself as
neurodivergent, with some exceptional skills. Some even think,
and I am one of them, that neurodiversity is the next stage in
evolution. OTOH, if you view yourself as an “F84.5” (Asperger’s)
or “F84.0” (ASD), you dismiss yourself as a unique individual
and throw yourself in the “box” with all F84.0s.
• Furthermore, you now give others the false impression that
they know what you are dealing with (“Oh, you’re autistic”) and
even make them segregate you as an “outlier.”
WHAT TO DO?
You give a freshly-minted therapist a
diagnosis and she will try to “fix it,” when not
only there is no “fix,” actually there is no
NEED to fix anything. The focus of
“treatment” should be the acquisition of
specific skills that are necessary to optimize
the quality of your client’s life.
Those skills can be one from the group of
Executive Functions, social skills,
communication skills, anger management,
sleep, etc.
TREATMENT STEP 1
Using your finest diagnostic instruments establish a correct diagnosis.
For our purposes, a correct diagnosis is one that:
1. All its criteria are met, as defined by the ICD-10
2. It’s paid for by the Payor (Medicaid/Medicare, commercial insurance, etc.)
a. No Learning Disabilities
b. No Personality Disorders
c. Only “Mental, Behavioral and Neurodevelopmental disorders” - F01-F99
3. Provides the Client with maximum resources and services
If you need help because there are too many symptoms or the descriptors are fuzzy,
you can ask Dr. Rózsa for help. He is pretty good at this stuff.
TREATMENT STEP 2
Put together the treatment team
THE TREATMENT TEAM - 1
Social Worker or Professional Counselor and other Behavioral Health Practitioners.
They assist people with ADHD and their loved ones through the entire journey, from
referral through diagnosis and treatment. They offer education, support, and tips for
managing it. They make sure everybody does their job, until such time that the parent
has acquired the parenting and advocacy skills the client needs.
Primary Care Physician (Pediatrician or Family Doctor). They are MDs and mostly to be
the first to attempt a diagnosis. Frequently, they refer the children and adolescents for
psychological evaluation. Some feel comfortable prescribing medication to mitigate the
children’s behavioral problems.
THE TREATMENT TEAM - 2



Psychologist. These are specialists who are trained to
diagnose and treat mental health conditions like ADHD. They
can give expert assessments and offer therapy. In Alabama,
they don’t prescribe medication.
Psychiatrist. They can also diagnose and treat mental health
disorders. They’re medical doctors, so they can prescribe drugs.
Speech Therapists. These specialists help with specific areas
that are affected by ADHD, such as language problems.
TREATMENT TEAM - 3


Other therapists such as family therapists. They can work
with people who have ADHD, their families, and school staff
members, they respond to family problems, find resources,
behavior, and help build life skills.
Occupational Therapists: Many of the children with complex ADHD
also present with Sensory Processing problems. Kids who struggle with
sensory processing issues are often referred to occupational therapists
(OTs). They do a treatment called “sensory integration therapy.”
TREATMENT TEAM - 4
The Teachers. Research in the field of
ADHD suggests that teachers who are
successful in educating children with
ADHD use a three-pronged strategy.
They begin by identifying the unique
needs of the child. For example, the
teacher determines how, when, and why
the child is inattentive, impulsive, and
hyperactive. The teacher then selects
different educational practices
associated with academic instruction,
behavioral interventions, and classroom
accommodations that are appropriate to
meet that child’s needs.
TREATMENT TEAM - 5
Special Education Teacher. Special Ed teachers are essential
to the scholastic success of a child with ADHD. They:
Assess students' skills and determine their educational needs.
 Adapt general lessons to meet students' needs.
 Develop Individualized Education Programs (IEPs) for each student.
 Plan activities that are specific to each student's abilities.

TREATMENT TEAM - 6
• The Parent. Parents must learn the limitations a child has and acquire behavior
management skills to be used throughout treatment. Parents who continue
using these skills even after treatment ends predicts improved parent- and
teacher-rated outcomes. Parents are their children’s advocates and, if needed,
they fight for resources, services, and accommodations that will ensure that
their children are successful.
A committed and effective parent is expected to eventually take over the roles of
social workers, counselors, and various therapists.
TREATMENT TEAM - 7
• The IEP Team. Supports and sets strategies for
behavior management, if behavior interferes
with the student’s learning or the learning of
others; language needs as related to the IEP as
outlined in the communication plan;
communication needs as outlined in the
communication plan; assistive technology
devices or services required in order to receive
FAPE, and any necessary accommodations in the
general education classroom.
THE IEP TEAM MEMBERS
1. The parents, who have the most information about a child’s strengths and needs
2. General education teacher(s) who can share information about classroom expectations and the
child’s performance
3. A special education teacher who has training and experience in educating children with
disabilities and in working with other educators to plan accommodations
4. An individual who can interpret the results of your child’s evaluation and use results to help plan
an appropriate instructional program
5. A representative of the school system who knows about special education services and has the
authority to commit resources
6. Individuals with knowledge or special expertise about the child that are invited by parent and/or
the school district – that’s mean YOU, the therapist!
7. Representatives from transition services agencies, when such services are being discussed
8. Anyone invited by you that parents feel would be helpful during the IEP process. Let the school
know if you have invited someone.
9. The student, when appropriate and whenever transition is discussed
COMORBIDITIES
Let me remind you of the
usual Comorbidities that
people with ADHD have.
These will certainly have to
be objects of treatment.
INTEGRATIVE TREATMENT
•
•
•
•
•
•
•
•
•
•
Pharmacological Therapy
Parent Training
Family Therapy
Psychoeducation
Cognitive Behavioral Therapy
Dialectic Behavioral Therapy
Social Skills Training
Dietary Interventions
Special Education and IEP/504
Other therapies
PHARMACOLOGICAL THERAPY
We know that dysfunction in the frontosubcortical pathways and imbalances in the
dopaminergic and noradrenergic systems are
the neurological bases for ADHD. Much as
we, mental health practitioners, might not
like it, pharmacological treatment with
dopamine and norepinephrine transporter
blockers is essential in the management of
ADHD.
STIMULANTS
• Stimulants are the most common type of medication
prescribed for attention deficit disorder. They have the
longest track record for treating ADHD and the most
research to back up their effectiveness. The stimulant
class of medication includes widely used drugs such as
Ritalin, Adderall, and Dexedrine.
• Stimulants are believed to work by increasing
dopamine levels in the brain. Dopamine is associated
with motivation, pleasure, attention, and movement.
For many people with ADHD, stimulant medications
boost concentration and focus while reducing
hyperactive and impulsive behaviors.
I tell the parents that imagine the kid has
got a motor in his brain that’s going 100
miles per hour. The part of the brain that
is responsible for braking and steering is
asleep. The stimulants wake that part of
the brain up.
NON-STIMULANTS
• Non-stimulant ADHD medications are
considered second-line or third-line
treatments because the level of benefits
and response rates are significantly lower.
Meaning, stimulant medications are more
effective at relieving symptoms for a larger
percentage of people. Some non-stimulant
ADHD medications, like blood pressure
medications, work best when used in
addition to stimulant medications.
• Unlike quick-acting stimulants, nonstimulant ADHD medications may take up
to a week to attain full effectiveness. As a
result, it can take much longer to titrate
non-stimulant medications — that is, to
find the best dosage for maximum
symptom control with minimal side effects.
WHAT SHOULD WE EXPECT
It’s amazing what different people expect from
medications for ADHD. I am making this up right
now, but I am sure I am not too far off target:
1. The teacher wants the student to be quiet, don’t give
her any trouble, do his homework, and do well in the
exams. Zombification is not a bad thing.
2. The parent wants a kid to be obedient, go to sleep on
time, not give her guff, and get good grades.
3. The prescribing doctor hopes this is the solution for all
the kid’s problems and that she won’t see until next year’s
EPSDT Examination.
4. The father thinks there is nothing wrong with the kid
and he needs no medication
5. Grandmother thinks her grandson just needs a good
whooping
INSTEAD, WHAT WE SHOULD BE LOOKING FOR
BEHAVIORS THAT IMPROVE WITH THE RIGHT MEDICATION
1. Fidgeting with hands or feet
8. Being easily distracted
2. Squirming in seat
3. Difficulty remaining seated
9. Failing to complete assigned
tasks.
4. Difficulty waiting turn.
10. Trouble paying attention.
5. Talking excessively
11. Careless/messy work.
6. Interrupting others
12. Not listening when spoken to
7. Being always “on the go”
13. Difficulty following directions
CLINICAL APPROACH TO
PHARMACOTHERAPY
Step 1
Extended release stimulant medications are first line in pharmacologic management of
ADHD symptoms. In general, stimulants improve core ADHD symptoms equally, but a
child or adolescent may respond better to one stimulant over another. Stimulant
medications are approximately equivalent in efficacy and side effects, but some children
and adolescents respond better to one over another.
Step 2
Starting with the first stimulant medication (either methylphenidate or amphetamine)
chosen, increased titration of dose should occur until maximum symptom benefit is
achieved without significant side effects or to the dose at which side effects are tolerable
and benefit outweighs risk.
PHARMACOTHERAPY
Step 3
• If one stimulant medication (either methylphenidate or amphetamine) does not work
at the highest appropriate dose, a medical practitioner should then consider trying the
other stimulant medication. Similarly, increased titration of dose of the other stimulant
medication should occur until maximum symptom benefit is achieved without significant
side effects.
Step 4
• If both (methylphenidate and amphetamine) stimulants have been tried without
producing benefit in ADHD symptoms or are not tolerated due to side effects, the next
step in ADHD medication management should be to consider trying non-stimulant
medications.
PHARMACOTHERAPY - 3
Along this step-wise pathway of medication
management of ADHD, the family and child or
adolescent should be fully involved in the decisionmaking process about use of medications. It is
important to explore potential concerns and practice
good collaboration and communication with the family,
other medical providers, behavioral therapists, and
school providers or other caregivers for the child. It is
recommended that systematic rating scales be used to
measure symptoms at baseline and throughout
treatment to monitor symptoms, performance, and
potential side effects
The Monitoring System is yours for the asking
ADHD MEDICATION
Medications alone do not change behaviors, teach social skills, build
academic skills, and teach emotional regulation or how to cope with
anger or frustration. Collaboration with caregivers, schools, and other
behavioral interventions in conjunction with pharmacologic therapy can
help with these essential skills for children and adolescents with ADHD.
We have to help the parents with:
1. Agreeing to medication management
2. Speaking up about it to the prescribing physician
3. The monitoring of the medication’s effectiveness
N.B. I will provide you with booklets for helping parents
understand medication management for ADHD
LET’S REVIEW
So far…
Step 1. We got the diagnosis
Step 2. We helped the parents put together the treatment team
Step 3. We coached the parents in IEPs and 504 Plans
Step 4. We helped parents understand medication management
MY JOB - IF I WAS ASKED
STEP 5 - THE REAL PROBLEMS
Other than comorbidities, the REAL Problems that children and
adolescents with ADHD have to deal with:








Anger

Low Self-Esteem

Inability to communicate

Social ineptitude

Emotional dysregulation

Executive dysfunction

Rejection Sensitive Dysphoria 
Sensory processing

peculiarities
 “Bad behavior”
Lying
Academic underachievement
Sleep problems
Time blindness
Impulse control
Discipline
Tantrums
Meltdowns
NEXT STEP IN MANAGEMENT OF ADHD
RESTRUCTURING OUR THINKING
So far, you must admit, we have been fairly conservative in our
thinking. About the only non-traditional idea that we introduced
is the concept of NEURODIVERSITY.
The implications that I meant to provoke is that we are dealing
with infinite diversity of dysfunctions, or infinitely varieties of
individuals, with an infinite number of genetic and
environmental determinants. All in all, you may have thought
that the task of fixing an individual with ADHD and all its
attendant comorbidities would be an impossible task.
Unless… unless… we reduce this potentially unsolvable puzzle to
a single domain of human endeavors:
EXECUTIVE FUNCTION
EXECUTIVE FUNCTION
Executive functions (EF) can be viewed as a multidimensional
construct that encapsulates higher-order cognitive processes
responsible for guiding, directing, and managing cognitive,
emotional, and behavioral functions, particularly during novel
problem situations. There are several cognitive processes
associated with EF, but the major elements include anticipation,
goal selection, planning, initiation, self-regulation, mental
flexibility, attention, and utilization of feedback.
These processes develop throughout childhood and
adolescence and are invaluable to the cognitive, behavioral,
emotional, and social functioning of the individual originating a
variety of difficulties when impaired.
• Just as an air traffic control system at a busy
airport safely manages the arrivals and departures
of many aircraft on multiple runways, the brain
needs this skill set to filter distractions, prioritize
tasks, set and achieve goals, and control
impulses.
• Children aren’t born with these skills—they
are born with the potential to develop
them. Some children may need more support
than others to develop these skills. In other
situations, if children do not get what they need
from their relationships with adults and the
conditions in their environments—or (worse) if
those influences are sources of toxic stress—their
skill development can be seriously delayed or
impaired. Adverse environments resulting
from neglect, abuse, and/or violence may expose
children to toxic stress, which can disrupt brain
architecture and impair the development of
executive function.
EF-2
EF-3


Emotional Control:
The ability to manage emotions in order to achieve goals, complete tasks, or control
and direct behavior. A young child with this skill is able to recover from a
disappointment in a short time. A teenager is able to manage the anxiety of a game or
test and still perform.
Flexibility:
The ability to revise plans in the face of obstacles, setbacks, new information or
mistakes. It relates to an adaptability to changing conditions. A young child can adjust
to a change in plans without major distress. A high school student can accept an
alternative such as a different job when the first choice is not available.
EF-4


Goal-directed persistence:
The capacity to have a goal, follow through to the completion of the goal, and not be put off by
or distracted by competing interests. A first grader can complete a job in order to get to recess.
A teenager can earn and save money over time to buy something of importance.
Metacognition:
The ability to stand back and take a birds-eye view of oneself in a situation. It is an ability to
observe how you problem solve. It also includes self-monitoring and self-evaluative skills (e.g.,
asking yourself, “How am I doing? or How did I do?”). A young child can change behavior is
response to feedback from an adult. A teenager can monitor and critique her performance and
improve it by observing others who are more skilled.
EF-5


Organization:
The ability to create and maintain systems to keep track of information or materials. A
young child can, with a reminder, put toys in a designated place. An adolescent can
organize and locate sports equipment.
Planning/Prioritization:
The ability to create a roadmap to reach a goal or to complete a task. It also involves
being able to make decisions about what’s important to focus on and what’s not
important. A young child, with coaching, can think of options to settle a peer conflict.
A teenager can formulate a plan to get a job.
EF-6


Response Inhibition:
The capacity to think before you act – this ability to resist the urge to say or do something
allows us the time to evaluate a situation and how our behavior might impact it. In the young
child, waiting for a short period without being disruptive is an example of response inhibition
while in the adolescent it would be demonstrated by accepting a referee’s call without an
argument.
Stress Tolerance:
The ability to thrive in stressful situations and to cope with uncertainty, change, and
performance demands. We generally reserve our discussion of this skill to adults, since it
seems more relevant with this population. We find it helps people understand the kind of work
environment they do best in.
EF-7


Sustained Attention:
The capacity to maintain attention to a situation or task in spite of distractibility,
fatigue, or boredom. Completing a 5-minute chore with occasional supervision is an
example of sustained attention in the younger child. The teenager is able to attend to
homework, with short breaks, for one to two hours.
Task Initiation:
The ability to begin projects without undue procrastination, in an efficient or timely
fashion. A young child is able to start a chore or assignment right after instructions are
given. A high school student does not wait until the last minute to begin a project.
EF-8


Time Management:
The capacity to estimate how much time one has, how to allocate it, and how to stay within
time limits and deadlines. It also involves a sense that time is important. A young child can
complete a short job within a time limit set by an adult. A high school student can establish a
schedule to meet task deadlines.
Working Memory:
The ability to hold information in memory while performing complex tasks. It incorporates the
ability to draw on past learning or experience to apply to the situation at hand or to project
into the future. A young child, for example can hold in mind and follow 1-2 step directions
while the middle school child can remember the expectations of multiple teachers.
SIGNS OF EXECUTIVE (DYS)FUNCTION ISSUES
WORKING MEMORY
• Does not connect previous learning with current
learning
• Difficulty remembering sounds and words
• Difficulty forming letters for writing
• Forgets the sequence for spelling
• Forgets what has been read
• Difficulty memorizing facts
• Difficulty remembering steps of a process
• Starts talking and forgets what they are saying in
midsentence
E(DYS)F-2
PRIORITIZING, ORGANIZING, SEQUENCING, MANAGING TIME, AND
PLANNING
•
•
•
•
•
•
•
•
•
•
Is not goal minded and does not plan ahead
Time management issues such as loses track of time
Has difficulty determining a task sequence
Becomes overwhelmed with long term assignments
Becomes overwhelmed when there is a need to balance multiple tasks
Cannot find materials
Does not record assignments
Rushes through assignments
Submits assignments late
Difficulty completing homework
E(DYS)F-3
ATTENDING, INITIATING, AND FOCUSING
• Appears to be daydreaming in class
• Procrastinates starting assignments
• Distracted easily
• Fidgets
• Has difficulty focusing on a speaker
• Asks questions or makes comments that do not match the
subject at hand
• Has to reread information multiple times
• Insecure about how to move forward with an assignment
E(DYS)F-4
SOCIAL/EMOTIONAL AND INHIBITING
· Difficulty filtering inappropriate comments
· Exhibits class clown behaviors
· Interrupts others
· Does not adjust emotions for different experiences
· Recognizes behavior needs to be improved but unable to
control it
· Reacts before thinking
· Poor relationships with peers and adults
· May refuse to participate in class due to stress,
frustration, sadness, shyness, lack of confidence, etc.
E(DYS)F-5
COMMUNICATING, COGNITIVE FLEXIBILITY, SHIFTING









Difficulty with oral language
May have a limited vocabulary
Difficulty with written language
May have an aversion to handwriting
Trouble interpreting body language
Difficulty understanding the intent of a verbal message
Resistant to change—perseverates and is ritualistic
Difficulty shifting from one activity to another
Inflexible thinking
E(DYS)F-6
Some students may begin a downward spiral as early as preschool.
If this spiral is not stopped, it may result in retention, or worse—
dropping out. While there are usually multiple reasons for poor
student outcomes, there is often a similar pattern for students with
executive function weaknesses. These students may






not understand all the demands made upon them,
find it difficult to pay attention,
have troubling remembering what they have been taught,
not always follow the rules,
find it difficult to get along with others, or
not begin work in a timely manner.
When parents and teachers fail to recognize these characteristics
as pointing to executive function deficits, they wrongly assume that
the student is simply not trying and is not well behaved. This in
turn may lead to the student feeling that they don’t care for them.
EF
Do these (dys)functions
sound familiar? As seen
with youth with ADHD,
maybe? Asperger’s?
Depression? Anxiety?
Oppositional Defiance?
Panic? Low Self-Esteem?
Anger? All of them, in
different proportions?
ASSESSING EXECUTIVE FUNCTION
The Childhood Executive Functioning Inventory (CHEXI) is free. It is a rating instrument that was developed in 2008 for
measuring executive functioning in children age 4-12, although it has been used with children as young as 3 years
A teenage version of this instrument called the Teenage Executive Functioning Inventory (TEXI) is also available












Response Inhibition – ability to control one’s behavior
Working Memory – ability to draw on past learning to apply to a present problem
Emotional Control – the ability to manage emotions
Sustained Attention – the ability to keep focus in spite of distractions, boredom or fatigue
Task Initiation – the ability to start tasks without procrastinating
Planning/Prioritization – the ability to decide what’s important and make a road map to complete the task
Organization – the ability to keep track of information or materials
Time Management – the ability to estimate the time a task will take as well as to complete tasks on time
Goal-Directed Persistence – the ability to create goals and manage one’s attention and
energy to reach the goals
Flexibility – the ability to change plans when faced with mistakes, obstacles or new information
Metacognition – includes self-monitoring and self-evaluation.
N.B. This is what I use
EF ASSESSMENT
BRIEF® - Behavior Rating Inventory of Executive Function®
(available from PAR)
1. Eight clinical scales (Inhibit, Shift, Emotional Control, Initiate,
Working Memory, Plan/Organize, Organization of Materials,
Monitor) and two validity scales (Inconsistency and Negativity)
give the clinician a well-rounded picture of the behavior of the
child or adolescent being rated.
2. The clinical scales form two broader Indexes (Behavioral
Regulation and Metacognition) and an overall score, the Global
Executive Composite.
3. The Working Memory and Inhibit scales differentiate among
ADHD subtypes.
EF ASSESSMENT -2
Tests that measure a child’s ability to inhibit a response:
1. The Trail Making Test asks a child to connect a series of dots, alternating between a sequence of
numbers and letters. It’s a test of motor planning, visual attention, scanning and the ability to shift
set (see f below).
2. Stroop Color and Word Test (ages 5 to 14; adult version starts at 15)
3. The Color-Word Interference Test of Delis-Kaplan Executive Function System (D-KEFS) (ages 8
and up)
What they measure: A child’s ability to hold back on giving an automatic response, or the ability to
think through something before acting.
Why it’s important:
Inhibitory control is tied to self-control . It allows kids to think before they act. It also allows them to
assess each new situation and consider the correct or most effective way to respond.
EF ASSESSMENT -3
Tests that measure a child’s working memory skills:
1. The Working Memory Index from the Wechsler Intelligence Scale for Children (WISC) asks a child to
remember strings of numbers or do mental arithmetic.
2. The California Verbal Learning Test (CVLT) asks a child to remember and recall a shopping list
3. Digit Span and Spatial Span subtests of the Wechsler Intelligence Test for Children (WISC) (ages 6 to 16)
4. Working memory tasks in the WJ-III Cognitive battery (ages 2 and up)
What they measure: The Digit Span test measures verbal working memory (the ability to store information
that’s heard). The Spatial Span test measures visual working memory (the ability to store information that’s
seen).
Why they’re important: Working memory is an executive function that allows kids to hold onto new
information in order to put it to use. (It’s also affected by attention .)
EF ASSESSMENT - 4
Tests that measure a child’s ability to sustain attention:
1. The Conners Continuous Performance Test (CPT-3) is a computerized test where letters appear
on the screen and the child must press the space bar for all letters except for one specific letter
or picture. It measures the ability to remain vigilant, show consistency of attentional focus, to
respond quickly and to inhibit responding (see a above).
2. Test of Variables of Attention (TOVA) (ages 4 and up)
3. Integrated Visual and Auditory CPT (IVA-2) (ages 6 and up).
Why it’s important: The ability to pay attention is a key executive function. Trouble with attention is a
hallmark of ADHD . While this test isn’t an assessment for ADHD, it might signal that a child
struggles with attention. Learn more about the link between ADHD and executive functioning issues .
EF ASSESSMENT - 5
Tests that assess inhibitory control
1. Stroop Color and Word Test (ages 5 to 14; adult version starts at 15)
2. The Color-Word Interference Test of Delis-Kaplan Executive Function System (D-KEFS)
What they measure: A child’s ability to hold back on giving an automatic response, or the ability to
think through something before acting.
Why it’s important: Inhibitory control is tied to self-control. It allows kids to think before they act. It
also allows them to assess each new situation and consider the correct or most effective way to
respond.
EF ASSESSMENT - 6
Tests that assess concept formation
1. Matrix Analogies Test (ages 5 to 17)
2. Naglieri Nonverbal Ability Test (ages 4 to 18), WISC-V Matrix Reasoning (ages 6 to 16)
What they measure: The ability to form classes of items based on what they have in common; the
ability to figure out patterns or relationships between objects.
Why it’s important: Concept formation allows kids to see relationships between things and develop
ideas based on what they already know about them. It’s important for abstract thinking.
EF ASSESSMENT - 7
Tests that assess set shifting
1.
2.
3.
4.
Wisconsin Card Sorting Test (ages 7 and up)
The Sorting Test of D-KEFS (ages 8 and up)
Minnesota Executive Function Scale (MEFS) (ages 2 and up)
Trail Making Tests
What they measure: A child’s ability to shift from one task to another. It also measures concept
formation.
Why it’s important: This executive function allows kids to shift their attention and move from one task
or situation to another. This type of flexible thinking helps kids see new ways of doing things, or try
something else when the first approach doesn’t work
EF ASSESSMENT - 8
Tests that assess word and idea generation
1. Controlled Oral Word Association Test (ages 5 to 16)
2. Verbal Fluency Test in the D-KEFS (ages 8 and up); Word Generation subtest in the NEPSY-II (ages 3
to 16)
What they measure: The ability to think of words and generate ideas. (It also looks at set shifting and
processing speed in some versions.)
Why it’s important: Kids rely on executive functioning to solve problems. Being able to quickly come up
with words and ideas is key to problem-solving.
EF ASSESSMENT - 8
Task Initiation
Initiation refers to the generation of ideas and alternatives to produce mental sets. This component of
executive functioning involves the ability to begin a task or activity and independently generate ideas,
responses, or problem‐ solving strategies.
Tests that measure inhibition include the
1. Go/No‐Go Test
2. The Stroop Test.
The Executive Function Guidebook by Roberta I. Strosnider and Valerie Saxton Sharpe
Blank templates, modifiable versions of materials, and strategy cards can be found at
http://resources.corwin.com/ExecutiveFunctioning
Tests that assess organization and planning skills
1. Tower of Hanoi (ages 5 and up)
2. The Tower Test of D-KEFS (ages 8 and up); Rey–Osterrieth Complex Figure Test (ages 6 and up)
What they measure: The ability to plan, sequence, and organize information for problem-solving.
It can also assess working memory and inhibitory control.
Why it’s important: Planning, sequencing , and organizational skills are key to following directions
and completing tasks efficiently. They’re also important when it comes to participating in complex
discussion. Kids who have trouble with executive function often struggle with these skills.
Tests that assess word and idea generation
1. Controlled Oral Word Association Test (ages 5 to 16)
2. Verbal Fluency Test in the D-KEFS (ages 8 and up); Word Generation subtest in the NEPSY-II
(ages 3 to 16)
What it measures: The ability to think of words and generate ideas. (It also looks at set shifting
and processing speed in some versions.)
Why it’s important: Kids rely on executive functioning to solve problems. Being able to quickly
come up with words and ideas is key to problem-solving
MAIN POINTS ABOUT EF TESTING
• Tests for executive function look at a variety of skills.
• Some tests measure the ability to pay attention.
• It’s important that evaluators look at all test results together to
figure out what your child struggles with — and what will help.
PULLING IT TOGETHER
Semantic map of executive function and related terms
HOW EF TRAINING WORKS
Analysis of a person’s EF is on three levels, from neural processes to the neurocognitive skills, to the
behavioral consequences (e.g. of attentional control, goal-directed problem solving). What starts as a neural
process becomes a behavior and in turn the behavior modifies the neural process. This is the basis of helping
kids develop Executive Functions.
WHO DOES THE TESTING?
Once we established a diagnosis of ADHD, or,
as turns out, almost any other mental,
emotional, or behavioral issue we train the
parents to become advocates in asking the
school to perform EF Testing and educational
remediation. The Special Education teachers in
almost all middle and high schools have those
available to them, if not they will pay to have
them performed by an external evaluator or a
school psychologist.
DID WE JUST WORK OURSELVES OUT OF A JOB?
Actually, we, therapists, cognitive-behaviorists,
counselors, social workers, etc. are just starting.
Because there are CONSEQUENCES to Executive
Dysregulation!
The first of which is:
EMOTIONAL DYSREGULATION
Why do you think the 14-year-old undiagnosed girl is
cutting herself? Why do you think the 13-old-boy
brings a knife to school when he gets teased by a
classmate? Anger? Promiscuity? Disruptive Mood
Dysregulation Disorder, anyone? Name it… it’s ED!
EMOTIONAL DYSREGULATION
One of the most effective methods of treating emotional dysregulation is dialectical behavioral
therapy (DBT). In DBT patients/clients are taught skills and strategies for managing emotions,
handling conflict, and building tolerance for uncomfortable feelings.
Inasmuch as DBT is a synthesis of several therapeutic approaches, it was designed to primarily to
treat disorders involving emotional dysregulation. I was privileged to be in one of Marsha
Linehan’s early workshops on DBT as applied to Pain Management, which was my specialty for 20
years. Once I worked my way through her two-day workshop I was sold. You can use DBT for
patients with borderline personality disorder, extreme emotional lability and poor anger
management
DBT
DBT can be used to teach young people dealing with emotional dysregulation a number of
skills, including:
•
•
•
•
•
•
•
Identifying and labeling emotions
Identifying obstacles to emotional control
Reducing vulnerability to the “emotion mind”
Cultivating positive emotional events
Increasing mindfulness of current emotions
Taking “opposite action,” i.e. acting opposite to current negative emotions
Applying distress tolerance techniques
DBT Tools: https://dbt.tools/emotional_regulation/index.php
DBT
Here are some gold standards that you should use
DBT FOR PARENTS
MORE EF GOLD STANDARDS
WHAT, NO CBT?
You are not going to use Cognitive-Behavior Therapy with Children for
several reasons:
1. It doesn’t work with them on one hour a week basis
2. You are not there: not at home, not at school, not socially
3. Whatever you “fix” in therapy in an hour, mother is going to undo in
15 seconds
BEHAVIORAL PARENT TRAINING
• Behavioral parent training (BPT) is one of the three most evidence-based treatments for ADHD
along with medication and school accommodations and interventions.
• When BPT is used along with medication, it can boost the effectiveness of medication.
Behavioral parent training is often necessary for learning more effective ways to cope with and
manage the symptoms of a child’s ADHD. There are typically high levels of stress associated with
ADHD in children, which also affects their parents and families.
• There are a variety of BPT programs and manuals; most share a common set of principles and
methods. The most effective BPT programs consistently produce an increase in positive parentchild interactions and emotional communication skills, teach strategies to improve parenting
consistency, and require parents to practice during the training sessions.
Positive Parenting Program
Triple P Programs draw on research, social learning, cognitive
behavioral therapy and developmental theory. The programs focus
on teaching parents the skills they need to address and prevent
behavioral and emotional problems in their children. It includes a
range of interventions, with increasing intensity, depending on
your child’s age, and the ability to choose your own parenting
goals based on your beliefs and values.
Started more than 30 years ago, the program now has more than
690 published papers and more than 240 clinical trials, studies,
and evaluations..
INCREDIBLE YEARS PARENTING PROGRAM
Incredible Years is a set of three developmentally based curricula for parents, teachers,
and children. Designed for children ages 2-12, it has been shown to improve behaviors for
up to 80 percent of participating children.
The parent program emphasizes skills known to promote children’s social skills and
reduce behavioral problems, while building parents’ interpersonal skills. With 14
programs designed for specific ages, parents, teachers, and children learn skills and
strategies for helping children regulate their emotions, improve their social skills and
academic performance.
PARENT-CHILD INTERACTION THERAPY
Parent-Child Interaction Therapy (PCIT) is an in-person therapy that focuses on
improving the quality of the parent-child relationship and changing parent-child
interaction patterns to promote a healthy family relationship. Using evidence-based
protocols, PCIT International certifies trainers to provide expert training and consultation
in their protocol.
The program uses two treatment phases:
1. The first focuses on helping children feel calm and secure in their relationships, and
feeling good about themselves.
2. The second focuses on building the parenting skills to manage challenging behaviors
while remaining calm, confident and consistent in your approach to discipline.
STAR PARENTING
The STAR curriculum helps parents of young children focus on
responding rather than reacting, and is based on developmental
and cognitive-behavioral theories and drawing from authoritative
parenting. Experimental outcomes show a reduction in parent
stress, anger and aggression, and a decrease in harsh verbal or
corporal punishment.
STAR Parenting teaches a problem-solving process, and strategies
and tools for providing child guidance for managing emotions,
behavior and conflict.
STRENGTHENING FAMILIES PROGRAM
The Strengthening Families Program is a 14-session program
designed to develop parenting, children’s social and family life skills.
Parents and children participate in sessions separately and together.
Implemented in over 35 countries, SFP is culturally sensitive rather
than culturally specific.
Outcomes include greater family strength and resilience, and
reduced risk factors for problem behaviors. With curriculum for
preschool, elementary age, early teens, and high school age
children, SFP is widely used in homes, schools, churches, and
community settings.
PARENT MANAGEMENT TRAINING
Parent Management Training (PMT) is designed for children
ages 2-17 and focused primarily on their parents, though
children may participate in some sessions. Parents are taught
skills to more effectively manage challenging behaviors through
modeling and role-playing. Between sessions, parents practice
at home with their children. Training programs typically include
at least 10 sessions.
PMT has been shown to be effective in decreasing oppositional,
aggressive and antisocial behavior, with strong postintervention results.
SYSTEMATIC TRAINING FOR EFFECTIVE
PARENTING (STEP)
The STEP program was launched in 1976 and
offers three programs focused on different
age groups and a Spanish-language version
for parents of children 6-12. Studies related
to the program conducted from 1976 to 1999
indicate significant positive change in
attitudes toward parenting, empathy toward
children, family functioning and stress levels,
and behavior.
ANGER MANAGEMENT
Cognitive–behavioral therapy (CBT) has been found to be an effective, time-limited treatment for
anger problems.
Four types of CBT interventions, theoretically unified by principles of social learning theory, are
most often used when treating anger management problems:
• Relaxation training targets emotional and physiological components of anger.
• Cognitive interventions target cognitive processes such as building awareness of cues and
triggers, hostile appraisals and attributions, maladaptive beliefs, and inflammatory thinking
• Communication skills interventions target strengthening assertiveness and conflict resolution
skills. • Combined interventions integrate two or more CBT interventions and target multiple
response domains.
OK, OK, so I lied…you WILL use CBT with kids for Anger Management Training
ANGER MANAGEMENT - 2
The gold standards
SELF-ESTEEM
Imagine getting nothing but negative feedback from everyone, all your life because you
constantly break classroom etiquette by interrupting the teacher – eventually you will
experience rejection and isolation due to your emotional outbursts.
As a result you:
• feel frustrated, embarrassed, humiliated, demoralized and discouraged from failing over
and over again despite your best efforts
• find yourself being subjected to constant correction, redirection, criticism (and possibly
social rejection and isolation) from others
• come to anticipate or predict you will fail again in the near future, resulting in anxiety
and avoidance.
How would YOU feel?
SELF-ESTEEM - 2
Actually, as the students get more successful
with their Executive Function skills, anger
management skills, social skills, communication
skills, academically… with medication, with
classroom accommodations, with tutoring, with
therapies, their self-esteem automatically
improves.
But, we will still lay that responsibility on the
parents!
SELF-ESTEEM - 3
WHAT PARENTS CAN DO
1. Show them lots of love and be positive about them as a person – tell them what makes them special to you.
2. Set an example of having a positive attitude when faced with challenges.
3. Let them know you value effort rather than perfection. Children can miss out on lots because they don’t try due to their anxiety about not
‘succeeding’.
4. Encourage them to try new challenges themselves, and celebrate them for it. Phrases like “Well done, that was hard, and you managed it”
are good. Make the steps small at first, then increase the challenges.
5. They could set goals and make plans for things they’d like to accomplish. Keeping track builds good feelings about each milestone
achieved.
6. Let them know they should take pride in their opinions and ideas and not to be afraid to voice them. It’s ok when people disagree, we all
see things differently.
7. Give praise for their successes, and don’t focus on areas where they have not done so well.
8. Reassure them it’s OK to make mistakes and that it’s all part of life. Getting it wrong is not the end of the world and happens to everyone.
9. Don’t be too critical and don’t put them down – if you are unhappy with their behavior, say this but make clear that you still love them.
SELF-ESTEEM - 4
10 Acknowledge their feelings and help them express their feelings in words. For example, encourage them to say, “I’m
upset because...” or “I feel happy when...”
11. Encourage them to face down the way they criticize themselves; change the niggling, negative little inner voice into
positive thoughts.
12. Focus on what goes well. Get them into the habit of saying or writing down three good things that went well that day.
13. Use creativity to help the child express themselves – art, drama, music
14. Help children discover and develop their talents, through clubs, groups and activities. Finding something they are good
at provides a huge boost to their feelings of self-worth.
15. Get them involved with community projects that make a difference to someone else to develop a more positive opinion
of themselves.
16. Get them outside, get them active, get them healthy.
17. Allocate 20 minutes each day to chat, laugh, do something together, have fun
18. Make sure your child’s school is aware they are struggling with self-esteem – many have mentoring or buddying
schemes.
SELF-ESTEEM - 5
REJECTION SENSITIVE DYSPHORIA
No one likes rejection or feeling like a failure. But
for people with attention deficit disorder these
feelings are debilitating — and may manifest as
either crippling sadness or uncontrollable rage.
• There’s a name for this phenomenon: Rejection
Sensitive Dysphoria, or RSD. In people with
ADHD, RSD can lead to an all-encompassing
need to please others, or it can result in
someone with ADHD giving up on anything that
is perceived to have a risk of failure
REJECTION SENSITIVE DYSPHORIA - 2
Signs of RSD
•
Sudden emotional outbursts following real or perceived criticism or rejection
•
Withdrawal from social situations
•
Negative self-talk and thoughts of self-harm
•
Avoidance of social settings in which they might fail or be criticized
•
Low self-esteem and poor self-perception
•
Constant harsh and negative self-talk that leads them to become "their own worst enemy"
•
Rumination and perseveration
•
Relationship problems, especially feeling constantly attacked and responding defensively
REJECTION SENSITIVE DYSPHORIA-3
TREATMENT
• There is NO effective Psychotherapy modality that work
consistently. RSD episodes hit suddenly and without warning.
• Medication is sometimes used to treat RSD. The alpha agonist
medications, guanfacine and
• clonidine, have been FDA-approved for the treatment of ADHD
for decades, but were not directly associated with the terms of
rejection sensitivity and emotional dysregulation. Nonetheless, the
symptoms of RSD/ED can be significantly relieved with clonidine
and guanfacine in about 60% of adolescents and adults.
SLEEP PROBLEMS
Sleep problems are serious and ubiquitous.
This issues are complex and the solutions
include first to resolve any medical problems.
We will do a whole session on this. Meanwhile,
the gold standard in the field is Harriet
Hiscock and Emma Sciberras’ workbook.
WHAT ABOUT…?
Will not cover:
Social Skills Training for social ineptitude – most of you seem well-versed in that,
if not, we can have a whole session on that;
Communication Skills Training: you are all good with that; besides we will assign
some of the toe Speech Therapist; if you need a whole session on techniques we
can do that
BUT… BUT… BUT…
“There are all these books on CBT for ADHD!”
Sure there are. But you are not going to do it; the parents are!
DISCIPLINE
You are NOT going to do that, now
are you? Unless you want to move in
with the family.
Best resource, in my opinion is the
Kazdin Method. We can do a session
on Discipline, although I covered
some of that in the ODD session.
THERAPIES NOT USED IN ADHD
UNPROVEN TREATMENTS FOR ADHD
Optometric vision training (asserts that faulty eye movement and sensitivities cause the behavior
problems)
• Megavitamins and mineral supplements
• Anti-motion-sickness medication (to treat the inner ear)
• Treatment for candida yeast infection
• EEG biofeedback (training to increase brain-wave activity)
• Applied kinesiology (realigning bones in the skull)
• Person-oriented psychotherapy
• Psychoanalysis
• Chitchat Therapy
•
THERAPIES WE DON’T MENTION
• Equine
assisted psychotherapy
• Biofeedback therapy
• Neurobiofeedback therapy
• Sleep therapy
• Dance therapy
• Music therapy
• Art therapy
• Play therapy
WITHOUT TREATMENT
Do you know what’s the problem of those people who are leaning against the wall, on the street,
smoking, drinking, and succumbing to drug addiction… day after day, year after year, hopelessly?
Nobody gave them a leg-up when they needed it. Nobody helped!
Do you know that of the 2.2 million people who are incarcerated, 64 percent of jail inmates, 54
percent of state prisoners and 45 percent of federal prisoners have mental illnesses? Of those, 45%
of prisoners have ADHD!
WITHOUT TREATMENT - 2
If people with untreated ADHD are 4 to
9 times more likely to commit crimes
and go to jail, what’s more costly?
Treatment or prison? [picture]
As Dr. Martin Luther King, Jr., said in
1968, “I think that we’ve got to see
that a riot is the language of the
unheard.” Sometimes it takes a riot to
bring attention to needed change.
Unfortunately, the new action often
comes as a reaction to old pain.
WITHOUT TREATMENT - 3
In the 1960s, Americans stood and fought for equality, justice, voting, human and civil rights. Black
and white people took to the streets and held marches, sit-ins, rallies, and yes, riots. Black people
wanted to address taxation without representation, Jim Crow laws, racism and segregation. Whites
wanted to address a lot of the same issues for black people. Some whites were even willing to put
the issue of white privilege on the table.
But those are the symptoms. As always, it’s the causes that matter.
What is going to happen to the 200,000 poor children in Alabama with mental, emotional, and
behavioral problems? Only 10% are being helped!
THE ANSWER
Care to guess what happens to kids who get
marginalized, suspended, expelled, or promoted
without education? What happens to kids who are
disrespectful because were never taught social and
communications skills? How about kids who suffer
with anxiety, no organizational skills, cannot follow
instructions, and have impulse control problems?
What if we created an army of competent,
dedicated, and passionate therapists and
counselors who can help those kids?
RESOURCES
1. I will provide a pdf file of this PowerPoint Presentation to all attendees
2. I have hundreds and hundreds of books and articles on ADHD-related topics
3. I have quite a large library of handouts, pamphlets, how-to manuals, etc. that
you can give to parents
4. Ditto for Worksheets, Forms, Monitoring methods, diaries, etc.
5. All of this will be uploaded to my DropBox “Supervision – ADHD” Directory. If
you ask for it, I will send you the link.
6. I have written a short little story about a Family of Neurodivergent People:
The Rózsas. It’s personal, so I will send it only to people who request it
directly.
YOU THOUGHT YOU WERE A THERAPIST
I bet that until today most of you thought you were just therapists
I hope that today you realized that are much more than that. In fact, you are all
AGENTS OF CHANGE
in other words…
YOU ARE ALL BUTTEFLIES
You may not know today or tomorrow
the changes you have created, but
one day, maybe 10 years from, you
will be at Target and somebody is
going to jump you and hug you, you
won’t know who they are, anymore,
but they know you. They know that
because of you, they are alive, not on
drugs, and not in prison, and not a
“weirdo.”