How to Assist Youth with ADHD

- All right, thank you all for being here, good morning, everyone, and welcome. Thank you all for being here today on our webinar on how to assist youth with ADHD, brought to you by Strengthening the Heartland. My name is Anie Wheeler, and I am a member of the Strengthening the Heartland team. Before we get started, I wanted to let you know that if you have any questions throughout the presentation, please feel free to type those into the question box. We will go through those at the end of the

presentation, and I will relay those to the speaker. And at the end of today's presentation, we ask you fill out short survey for us. You will see a link to that in the chat box at the end. The survey helps us with feedback, and we really appreciate your recommendations for future topics in our webinars series. To see any of our previous webinars and to stay updated about our projects, head to our YouTube channel, Strengthening the Heartland. So without further ado, I'd like to introduce our spe

aker for today, Rachael Moe. - Hello, welcome everybody. My name is Rachael Moe. I'm a licensed professional counselor in the state of South Dakota, as well as in Colorado, and today I'm very excited to present to you some information from researchers in the field on ADHD. Most of the information from these slides will come from research by Dr. Russell Barkley, Peg Dawson, and Richard Guare, as well as Cindy Goldrich, and two books that I have really loved in finding the research or following in

to ADHD are the books "Smart But Scattered" by Peg Dawson and Richard Guare, and they started the research back in about the 80's, and then "Eight Keys to Parenting Children with ADHD" by Cindy Goldrich. So, we will go ahead and get started today. The goals of our presentation are really just to increase your understanding of ADHD, and introduce you to the idea of ADHD through the lens of executive functioning. The hope is that you'll be able to see ADHD as being on a spectrum, as well as unders

tanding that ADHD is a neurodevelopmental disorder. And we'll talk a little bit about what that looks like in the brain, as well as common symptoms and the diagnosis, and some tips and strategies as we get started. One thing I always talk about with clients and with the parents that I'm working with is that poor parenting does not cause ADHD. And we all have areas of strength and weaknesses, and executive functioning is something that we can all benefit from, adults as well as anybody in your cl

assroom. So the hope is that if you're working with kiddos, in terms of a counseling perspective, coaching perspective, teaching perspective, we'll give you some tips and strategies just to kind of introduce you to some ideas of how you can support executive functioning development and growth in youth. So I guess I just wanted to touch base briefly here and see what kind of population we have. So if you want to do a couple of check-ins, maybe where you're from, and how you have interactions with

kiddos, if your parents, therapists, teachers, whatever it is, just gives me an idea of who we have joining us today. - We have a CPS worker, assistant professor, special education, trained... excuse me, play therapist. You have a middle high school teacher slash administrator. FPC's. Security chief development, church volunteer, occasional rehabilitation counselor. A really good mix. - Perfect. Well, welcome everybody, and hopefully this presentation is helpful for you. You can kind of chat in

the comments as we go, and then we'll leave some time at the end for questions to dive in. And if there's areas that you're like, "Wow, I really enjoy this information. I want more tips and strategies on this," it's helpful for us to know if there's any interest and a need for future presentations, as well as areas to focus on later on. So, we'll start with just an introduction to ADHD with some facts. So they changed the term from ADD back in 1987. So sometimes you'll still hear individuals re

ference ADD, and they're referring to ADHD. When we talk about ADHD, there's really three different types. We have the hyperactivity, or the inattentive type. So hyperactivity, I always think of like Tigger the tiger where they're kind of all over the place and jumping around, and then the inattentiveness, that's kind of your daydreamer, and then we also have the combined type. So symptoms have to be evident in two or more settings, and they have to present before the age of 12. And so we hear a

lot now individuals who are being diagnosed with ADHD and their adulthood, and so they'll go back and do a full history, and kind of look at were these symptoms, or were these difficulties stemming before the age of 12. We'll see the symptoms impact them socially, academically, and sometimes occupationally, is what we'll talk about. And like I said, it has to be evident in two or more settings. The CDC in 2016 reported that 9.4% of children aged 2 through 17 would qualify for a diagnosis of ADH

D. So when you think about that in a classroom setting of 30 kids, that's a pretty big number of kids that are gonna be in there, and about 3 kids for a 30 kid classroom. So having some tips and strategies for classroom setup and management can be beneficial. And like I said, these tips and strategies for development of executive functioning can just be a great for working with children in general, because we all have executive functioning skills. We all have of weakness and then strength. It's

also interesting to know that ADHD is largely hereditary. So if you have an individual who has ADHD, 40% of children with ADHD have at least one parent that also has ADHD, and 30% will have a sibling. The research shows that 75% of these people continue to have symptoms into adulthood, and I always wonder, like do the 25% no longer have symptoms, or have they really developed tips and strategies to just reduce their emotional vulnerability, and adaptations within their environment so they can st

rive even with those symptoms presented? So they've learned a little bit about themselves, and they can be mindful about it. When we look at brain development, the images of the brain will show differences in the structure, and we see a lot of that in the loading and releasing of neuro-transmitters, and that's our dopamine, norepinephrine, and serotonin. And we need these areas in order to maintain alertness, increased focus, and sustained thought, effort, and motivation. So when we talk about e

xecutive functioning, we see the difficulties in these areas with ADHD, and a lot of that is because when you look at the brain scans, the prefrontal cortex is thinner, and it matures a lot slower, and might also have an under-stimulation in the reward and motivations center of the brain. So I hear a lot of like, "We put into place this reward chart and it was working, and then all of a sudden they lost interest." That's because the reward and motivation center of the brain is located in that pr

efrontal cortex, and it's thinner and it mature slower. So that's why those reward charts don't work, and they often need immediate feedback to stimulate the reward center of the brain. And we'll talk a little bit more about that as we go, but kind of one of the key things to keep in mind for individuals with ADHD, time is now, and it's not now. So we have to be immediate in our praise, and very specific in the praise in order for them to build that sense of mastery and confidence in what they'r

e doing. So, this is on the handout. So it's something that you can kind of refer back to, and it's just a nice little image, I think, of how ADHD can affect the brain and the different areas of the brain, and this is from research at Rapid University in February of 2017. So there's a lot of research out there on ADHD, and more and more we're beginning to understand how ADHD impacts executive functioning and its development. So executive functioning is really just the set of mental skills or pro

cesses that we have to do to manage ourselves and resources. So we have to be able to have these executive functioning skills to get anything done that we ever set out to do. These are regulating skills that help us to accomplish anything. And what we notice is that they're located in the prefrontal cortex, and for most individuals, they're fully developed around the age of 25 to 30, but individuals on brain scans, what we see, if they have ADHD, is that it develops about 30% slower, and Russell

Barkley says this is equivalent to about three to five years in terms of the development delay. So I would think of this as like, the really tall kid in kindergarten, right? It's not that they're struggling with like IQ. They usually score at average or above average, but a little bit more immature in their skill development. So sometimes our expectations is higher than what they're able to perform. So we have to teach or parent the child that we have, and Cindy Goldrich says this a lot, parent

that child that you have. And for me, that really has kind of settled in, and been something that I often think about just in general as a parent and as a clinician advocating for parents to step back and just kinda think of like, maybe your expectations are here, and we're not necessarily gonna lower the bar, but we're gonna look at what are they ready to learn? And let's start with some of those skill developments right now, and kind of taking off the edge of the expectation of what we believ

e our child should be, and more looking at what we would like our child to be able to accomplish as they grow. In order to have an accurate diagnosis, Cindy Goldrich states, that you will need to get an in-depth clinical history, both of the child and the family. This looks like having a physical exam to rule out any other possible causes like sleep apnea, thyroid concerns, a clinical assessment using a standardized behavior rating scale. Some respected rating scale are usually the Conners ratin

g scale, the Vanderbilt, and the Barkley Home and school Situations Questionnaire. Most commonly what we see in this area, and I'm at Sioux Falls, South Dakota, is the Conners rating scale. And the evaluation will be given to the parents, and to the teachers typically in those settings, so a clinical assessment with a standardized behavior rating scale. And we also, sometimes it's encouraged to look at any evaluation of the child's intelligence or aptitude just to rule out any other causes or co

ncerns. So now that we have kind of the facts of ADHD, and what that means, we're gonna look a little bit at how we can help. Again, we want to get a proper diagnosis. We also want to have education for those in the role of teaching, parenting, and supporting, and then we need to approve education as support, and make accommodations and modifications. In the handout that I provided, there's also a link to the See Dear Colleague Letter and Resources Guide on students with ADHD, and the reason I p

ut that in there is because if you're in the school system in July of 2016, the department of education clarified schools are obligated to provide students with ADHD an equal opportunity education, and so this is just the link for you to look at so you have a little bit more information of what that means. So let's go ahead and get started. So we're gonna go through executive functioning skills, and as we go through them, we're gonna go through kind of what develops at the earliest age, all the

way to the skills that take a little bit longer. In the handout, I typed out each of the executive functioning skills, as well as the definition of them, but you'll notice that I didn't put the tips or strategies, and that's to kind of just help you with note taking. So really all you have to focus on are these tips and strategies that I add for you, maybe thinking about the population you work with, what are some areas you would want to know? And then think about what areas maybe you'd want to

know a little bit more. So as we go through this, think about just one thing you might do different. And the first executive functioning skill we're gonna look at is impulse control. This is also referred to as response inhibition, and it's really the ability to think before you act. And this develops earlier on, and we see this first developing in the age of six months old, and that's really like, do I respond or do I not respond? That's the response inhibition at that age. When I think of impu

lse control, I always think of Dennis the Menace, that's who pops in my mind, right? By the time I think about what I'm gonna do, I already did it. So these are the kiddos that we see with the interrupting, the blurting, grabbing or throwing things. And it's 'cause their neurobiology is running on this ready, fire, and everybody who's around them is kind of thinking like, "This kid didn't even aim, they just went for it," right? So we see a lot with ADHD. One of the beautiful factors is that the

y can be very spontaneous, which can be great, but can also be a little bit scary, right? So this can be due to the lower dopamine levels that we see in the brain, and why many with ADHD may engage in risky behaviors. And our goal is really to help them learn to manage as best as they can, and be responsible for their actions. So some strategies on developing response inhibition and impulse control can start as early as just simple games that we play like Simon Says, or red light, green light, a

nd it's really just teaching them to wait and think, stop and pause. If you have a kiddo who struggles in this area, maybe you develop a private signal that lets them know to wait, think, and then go. We want this signal to be discrete, but distinctive, so that it can be used with play in a public areas, because the goal is to really help them develop these skills, but we don't want to put any kind of shame or embarrassment within that factor. In the classroom study, it might look like setting e

xpectations, being clear about those expectations, and then ignoring behaviors when possible. This example might reference to raising your hand before you answer a question. So the kiddo that struggles with impulse control, maybe blurts out the answer, and instead of drawing attention to the fact that he blurted out, we just wait for the person to raise their hands. We call on them, they answer the question, and then we praise that. "Oh, thanks so much for raising your hand. I'm glad that you we

re able to provide that information for us. Remember everybody, we just need to raise our hand before we share the answer if you'd like to be called on." And then this individual, we might do some immediate praise or rewarding, being very specific when they do follow through with that. Create pauses in your day, modeling, slowing down to help them slow down. So if you see the energy is way up here, and it's higher than the activity that we're doing in the moment, so they're struggling to focus o

r pay attention, we might just cue them in to take a couple deep breaths, and we might say, "Okay, everybody, we're gonna get started here, and I noticed everybody's coming back in from recess, and we're really excited. I'm glad to see everybody had a really good time. So let's just take a nice deep breath, everybody breathing in your nose. And I want you to fill that air all the way in your belly, and just kind of pause for a minute as you take a nice, slow, deep breath, just noticing where you

r breath enters and leaves your body. And in order to slow our nervous system down, it's really breathing in your nose for about a count of four. And then holding that breath for about the count of four. And blowing out of your mouth, like you're blowing through a straw, for six, five, four, three, two, one." And we'll be encouraged individuals or kiddos that we're working with to do this, because we notice their energy is way up here and we want to bring it down. We start by modeling it, right?

Let's take a nice deep breath, and even if they aren't doing it right away, we just do it. "Wow, you guys are so excited. Recess must've been really fun." Let's start to slow it down here as we shift our focus, because we're gonna get ready to start math, and I want everybody just to take a nice, deep breath. Maybe we ask them to take a nice drink of cool water, kind of slow down, right? I want to create pauses during the day in our transitions, and model that slowing down, especially when you

know you're coming from a high-energy activity to an area where maybe they need to slow down and focus. You want to have clear roles and expectations, and review these before gathering, and plan ahead on what to do if challenging behaviors happen. Like we talked about earlier, having a private signal that lets them know to wait and think, and then if we notice that they're really struggling and there's some impulse behaviors happening, maybe we give that signal, and then we take them outside for

just a quick little pause, quick little break, right? Get some fresh air, and like, "Wow, I noticed you're getting really excited in there. I just wanted to come out here and kind of regroup. Let's slow ourselves down. We're gonna go back in there. Remember, the expectation's that we keep our hands to ourselves," and kind of reviewing those clear rules and expectations with them again, and then reintegrating back into the environment that they were in. In a classroom setting, this might also lo

ok like preferred seating, and setting up behavior goals, and using immediacy with praise. I could talk probably a whole hour just on praise, and slowing down, and impulse control, and how do we be specific in our praise, and what that looks like. So we'll go ahead and move along. The next one is working memory, and our working memory is really just... kind of our ability to hold everything in mind, and where we store and recall information, right? And so this is like our memory box of keeping i

n mind everything that we have to remember, and what worked last time. So this starts in infancy, and we remember what you have to do, and there's nothing that we ask kids to do that doesn't require this. So when you think about math, sometimes we have to prompt them, like, remember what you did last time? And sometimes it's as simple as asking them to go inside and grab something, and the kiddo maybe struggles to remember why they went inside and what they did. I mean... I do that sometime. Lik

e, why did I walk into the kitchen, right? So remembering executive functioning skills are on this continuum. We all have strengths, and we all have areas of weakness, and it continues to develop. So some strategies is encouraging use of scratch paper for basic notes, post visual schedules and reminders, and to-do lists. I hear a lot of parents saying that they never thought about visual schedules, and then all of a sudden they're like, "Wow, that was really helpful." And it's as simple as areas

that you notice that maybe the kiddo is struggling with, like morning routine and what they do in the bathroom, and so maybe you have a picture of them brushing their teeth, taking pajamas on or off, morning or evening schedules and what that looks like, keeping it real simple with visual schedules. Teachers can use visual schedules for this then that, so kids understand like we're doing math now, and then this is coming. But also those who maybe struggle with certain areas can also anticipate

that they're gonna do this for a few minutes, and then they're gonna get to transition to taking a break, and then they have math coming up. So, I hear a lot from kiddos if there's an area that they're struggling with, because they have difficulties in working memory, like math. It feels like torture for them. So letting them know like, "Hey, we're just gonna do math for about 20 minutes, and then you're gonna get your break." And then maybe we have an activity or something for them to work off

some of that nervous anxiety, and then they come back. So walking through what worked last time with them, doing the steps with your child to work them through it, and then build independence from there. And I always say don't do for your child what they're capable of doing, but use prompts or cues to get them going. This is our heavy hitter. Emotional control. Most of the time for counseling, this is when I get the referral. It's difficulty managing their feelings or emotions, and when there's

a deficit, it's an identified problem due to the expression of the emotion, not the emotion in itself, right? All feelings serve a purpose, and for kiddos, sometimes learning how to regulate those feelings is a little bit harder. This is one of the things in the first year of life that is critical. And sometimes when we're looking at diagnosis with ADHD, it's also ruling out any history of trauma, because in early development, we start to develop emotional control based on having a reliable care

giver who models managing their own emotions, as well as tending to their emotions and their needs to help learn to self-soothe and regulate the nervous system. So at a young age, our job as adults is to be calm and collected, right? And really the best thing to do that is to be able to regulate your own emotion and your own nervous system so your child can borrow that nervous system, and then model for them how they handle it. Like I said, it really starts with you. So we have to be clear and e

xplicit in teaching our children how to regulate their emotions, and parenting the child that we have. How you react to your feelings is gonna impact how your child reacts to you, and to their feelings. So, calm is really kind of your control and your power in a parenting situation, and without calm, there is no opening for teaching, right? And I see it all the time, and even as a parent, I am guilty of it, right? You get to this place where you you've lost your calm, and the next thing you know

, you're going off on lectures and pleading and bribing and kind of going in, but your kid's hearing none of that, because their nervous system is regulating off of your nervous system, and both of you are firing way too high. So again, it's that comeback of like, okay, let's practice a pause. I noticed I'm getting frustrated. We're gonna take a deep breath, and kind of slow down here and regroup. Part of this too, is that negative emotions dull the cognition, right? So executive functioning ski

lls are all in the frontal lobe where our emotions kind of live in the back of the brain. This is our amygdala. And so when we have stress or pressure and anxiety, it increases the cortisol level that are running through our body, and it dulls the individual's ability to think or concentrate. So if a kiddo is struggling in a classroom setting, and all they're saying to themselves is, "I'm so stupid. I'm not good at math, I can't do this," right? Cortisol, cortisol, cortisol. It's all dumping, as

they're having really hard time regulating their emotions, they can't get started on the task, and they're struggling. And their energy is way up here, and so it's being able to just help them regulate their nervous system. But in order for us to do this, we need to be calm first and connect to the child and validate that feeling. "Well, I can tell you're really worked up right now. You're really frustrated. Let's take a few deep breaths and step back." The prefrontal cortex pretty much just tu

rns off when we have a lot of stress, and so our thinking and executive functioning skills aren't able to be accessed, and we run on this like rapid and reflexive responses. And this is usually what we think about is the fight or flight. But when we talk about fight or flight, most of the times we try to run away from a situation if we can, and if we can't run away from it, maybe we try and fight it off, or we shut down and we completely freeze. And then another one sometimes we don't think abou

t is fib, and we see this a lot in younger kiddos. We try to avoid the consequences, because we know that we're gonna get in trouble, and we know that this feeling is uncomfortable, and we don't want to feel this shame, and we don't want to feel this embarrassment anymore. We have all this cortisol and stress, and we're not thinking through it, right? And so they tell a fib. (Rachael chuckling) And then we're like, I saw you do that, right? So sometimes in kiddos, to help them regulate the emoti

ons, don't withhold information that you know. "I saw you draw on the wall, let's go clean it up together," right? Instead of, "Did you draw on the wall?" No, "I saw you draw on the wall. We're gonna go clean up together," being very specific about the facts and what you know, so that it kind of calms the nervous system. And you're telling them like, "I see you, I know this happened. Let's move on, let's work through this." How we speak to children really has the ability to motivate or trigger t

hem with a power struggle, and acknowledging the power struggle, and know if you want them to change, you're also gonna need to change your approach. So emotions can come out in defiance, which can be an attempt to protect themselves. So some strategies with emotion regulation is reflecting emotions with immediacy in the child and in ourselves, and being curious as to why this emotion is present. So validate self, and listen before we want to give our lectures and moving along and trying to just

get them to calm down, validate, stop, and listen. Calm yourself and your nervous system, and try and connect with the child, and notice and nurture before problem solving. So tend to the emotion first, give them the chance to access what they know, right? So the processing speed in individuals with ADHD is lower, so we need to give some space and time for them to process what has just happened. Connect to those feelings, slow down the nervous system so that the heart rate can flow down the blo

od, instead of going to the arms and legs can flow back to the heart, and the oxygen that's pumping the heart so fast can go back to the brain, and they can access those executive functioning skills. So sometimes it's not that they don't know the information or have the information, they can't access it in the moment, and that's where emotion regulation sometimes creates that barrier. And kids really learned by watching how we manage our own emotions, and that's gonna be the biggest tool in mode

ling that for them. Also teaching things like self-talk. So the research shows that self-talk goes straight to the amygdala, and that also calms the nervous system. So talking them through saying things like, you know, "What can I say to myself when I'm really frustrated?" You know, "What worked last time when you struggled with that math problem?" "Oh, you could raise your hand." So, maybe saying to yourself, "It's okay to ask for help, the teachers here to help," right? Self-talk reduces the r

esponses in the amygdala, paired with mindfulness, like controlled breathing, and practicing of calming that nervous system, as well as someone who is also calming their nervous system and tending to us, right? The caregiver in that situation, and our job is to really coach them into breaks, to regulate their emotions and work through them. Some will teach like zones of regulation, and that's helpful really in just creating this awareness of it, and having them be able to say what zone that they

're in, and then physical signs of emotions, teaching self-soothing needs, and it can be helpful to have a visual chart in this area too, of just ideas to do with certain behaviors occur or certain feelings occur for them. And you have a list of this options in a classroom setting, and you could also have individualized to the child. So the next executive function skill that develops would be sustained attention, and this is also our ability to shift and sustain attention, and shift our focus. S

o it's not that individuals with ADHD can't pay attention, it's that they struggle to pay attention in spite of, or when they're bored, right? And it's difficult to keep your attention when you're distracted or fatigued. So think of things like chores, and homework, and daily routines, and even us as adults that are like, "Gosh, I really don't want to fold that laundry, and it's been sitting there for a day. I'm just gonna start the dryer again, right?" We all have this, you know, where we notic

ed that we struggle with it. So when there's a deficit, there's a difficulty in screening out other stimuli, like background noise. We also noticed that individuals with ADHD can hyper-focus, and this usually occurs when they lock into one thought or activity that they lose track of other things, and this can make transitions difficult. Sometimes I'll have parents say like, "I was looking right at them, and they were looking right at me, and I told them what to do, and then they didn't do it. An

d then I said it again, and they didn't do it." So their focus is still on whatever is interesting to them, video, game, TV, whatever. And they might be looking at you, but that's not what they're hearing, that's not what they're focusing on. So trying to eliminate other stimuli or things that are going on in the background, and maybe asking them, "Look at me so I know that you're hearing me," and then asking them to repeat back what they heard. The goal would really be also to build the capacit

y to maintain attention to a task in spite of distraction, fatigue, or boredom. So start with what you know, and where your child is at, and if you know that they can sustain their attention for about 10 minutes, then we make a goal of let's work to 15. Be willing to sit with the child while they work on specific tasks that you know they struggle with sustaining their attention. We call this body doubling. So your presence can be grounding, and it's meant not to be punitive, but supportive. So i

f you're you know that your kid gets distracted when they start homework, we're not gonna leave the room when they do their homework, but we're gonna sit down next to them, and we're gonna say, "Okay, it's time to get our homework going. And while we're working on this, I'm gonna kind of sit here and read a book, and I'll check in on you in every couple of minutes." That's why sometimes with like an IEP or a 504, it can be beneficial to have smaller work areas, but also body doubling in areas. I

f they struggle to sustain attention with reading, maybe they do reading groups, and they take turns reading to each other. Different ideas or strategies that you can do, depending on the situation that you're in. We want to set goals, use breaks, and work to reduce the distractions. This is also where preferred seating, noise-canceling headphones, and smaller work areas can be helpful. The next developing executive functioning area is gonna be the task initiation. So this is the ability to make

yourself start a task, right? So think the opposite of procrastination. Deficits are noted when a child or adult may be aware of what they need to do, but they struggled to get started. So some strategies with this is helping your child notice when they're struggling to get started, and getting them to buy in on a starting time, and just kind of getting them to get going. So work on a connection to signal the transition with the visual time or calendars along with prompts, and try helping them

with the first step to get the momentum going to cue them into that. Don't do for your child what they're capable of doing to themselves or for theirselves, but maybe we kind of sit with them, we ground them, and then we say, "Okay, we're gonna start on this problem. Remember, the first step is this, right?" And we get them going. So help develop a shorter routine to signal that start time, and if possible, help them anticipate how long the activity may take so that they can visualize an end ins

ight. Again, like I said earlier, so often, if it's an area that creates a lot of stress, and they notice that they get all that cortisol, it's hard for them to focus, and they get frustrated, and maybe this is an area they noticed that they often get in trouble in, it feels like torture. So even though math is only 30, 45 minutes for them, that feels like you're asking them to do math for the entire day, and I cannot believe they're torturing me like this, right? I don't know how many times I h

ear where kids use that word, torture. The interesting fact is that procrastination really increases to our mid to late 20's, and then it gradually decreases after that. So, I don't know, I always think of myself, I was probably a queen of procrastination in college until I got to grad school, and kind of buckled down and realized, "Oh, okay, this is how I'm gonna get this working." The next one you look at is flexibility. When we talk about ADHD, flexibility is usually a strength, because they

kind of live in the here and now. And so if you suggest something, they're like a go with the flow, and they're ready do it, right? That's a spontaneous part of them, but we do see a struggle in individuals with autism, and about 50% of individuals who are on the autism spectrum also present with ADHD, so they can cling to the idea of planned things, and they struggle to do things out of order or different, you know, this is what we were supposed to do, and now we can't do that, why? What's goin

g on, right? We also see this in anxiety. So unplanned events can increase distress. Strategies are planning ahead. Explore problem solving ideas with a plan B. Stop and look at what the trigger was, and plan ahead and talk through it. Explore big deal versus little deal. I have a wonderful little kindergartner, and we use that statement a lot, because he'll get really excited, and he's talking about something that happened at the end of the school day. And I'm asking him about it, and he's gett

ing louder and louder and louder. And I'm like, "Hey buddy, is this a big deal, or a little deal?" "Little deal." "Okay, so why are we yelling? Let's just take a deep breath. Can you tell me one more time? I'm really trying to understand." And he'll slow himself down, but sometimes even just that self-talk, again, that's cuing in that amygdala, they're borrowing your nervous system. You're kind of drawing their attention to it and slowing them down. One book suggestion that came from Peg Dawson

is that "Solving Executive Functioning and Challenges" by Dr. Lauren Kenworthy, and this book really just explores the language around flexibility, and noticing the same things, like it looks like you're stuck. I wonder if we could try this. It's really empathizing with the frustration, and then moving them towards the problem solving, just like we talked about in emotion regulation. First, notice the emotion, validate that emotion. And then after we've been calm and we've connected, then we're

gonna work on problem solving or moving ahead. The next area is planning and prioritizing. So this was kind of like our roadmap, and they may struggle to identify what is important or where to start, and this skill takes the ability to anticipate future events. So it means you need an accurate understanding of time, and it requires the ability to apply structure or a system in a method with focus and attention. So this is a skill that develops way later in life, but sometimes in a school system,

we ask kids to do this at an early age. Like, we just got flyers sent home for school for the science fair, right? My kid's in kindergarten. He's not gonna plan and prioritize that. If he wants to do the science fair, a lot of that is gonna fall on us as parents, and helping them work on that and sticking to it. So body doubling, modeling, working through it, I'm not doing for him what he's capable of doing, but helping him with that timeline, and keeping him motivated and on task. Strategies i

s helping them work backwards from a goal to create a smaller task that can be planned to the present. Some practice, and this is one I do a lot in my clinical practice, and with kiddos. So like preschoolers and elementary, you can work on puzzles and explore a plan for working on the completion of a puzzle. The reason I like to use puzzles is because we get to see their working memory and asking questions, you know, "Have you ever done a puzzle before? What were your strategies in the past? Lik

e, what did you do?" And some will say like, "Oh, I noticed my mom does it. She always says the outside edges." "Oh, okay. So let's organize, let's put all the outside edges over here, and the inside over here." And then once they say that, because they said in their plan that they were gonna start with the outside edges, I take the inside edges away, because now it's no longer this impulse urge to grab the inside and start working, they only have the outside. And then I might cue him in of like

, "Okay, what do you notice about this piece? So what would the next piece look like? This one has a little bit of red on it, so we need something with some red and with some brown," right? And we help them kind of develop some of that planning and prioritizing, starting from the back and working the way up. It's got the visual cues with puzzles too, of like, oh, okay, you're having a hard time looking at this. Let's look at the picture of the puzzle, and see what it's supposed to look like at t

he end. And you know what, maybe we can figure out here and go from there. The next one that we talk about with strategies for middle school, this is planning and saving for a big item or desired toy, breaking down long-term projects or goals into smaller steps or tasks with deadlines. So if you work in a school setting, this can be a great thing to practice at a younger age is helping them, like if you know you have students in your class that are gonna participate in the science fair, making t

hat part of the class curriculum or project, and developing that planning and prioritizing of like, "Oh, okay. So let's start with creating this timeline of what you're gonna do and how that's gonna look," breaking it into smaller steps or tasks or deadlines. Maybe you have big projects. I know one of the schools I used to work in had like a wax museum presentation every year, where they got to dress up like a character and provide a history and a timeline and a big poster board, and it was alwa

ys really fascinating, but helping them work back from, "This is what we have to do, and it's due in February, and so where should we be in January, and then where should we be in December?" And having those check-in points. So remember, this is something that takes a really long time, and individuals start to show the ability to plan and prioritize around seventh and eighth grade. But in the school system, we're seeing a lot of the times they're being asked to do this in second and third grade,

and they just don't have the skills yet, right? So this is great that we start practicing and developing those skills, but to expect them to be able to do it isn't necessarily realistic, right? So we're not gonna lower the bar, but we're gonna meet them where they are, and we're gonna teach that skill development, and go from there. We also see some struggling in organization. So it's not that they can't get organized, it's maintaining the organization. So the next two that we're gonna, or next

couple we're gonna talk about here is organization and time management, and some people are really good at it, and some people aren't. And what I noticed is that it's often more frustrating for the people who are naturally good at organization, or time management, to be around people who just aren't, right? Because you're like, "I don't understand why they don't get it." So remember, if this is something you're naturally good at, that's great. And some people who aren't, maybe it's been a famil

y goal, and I often look at that. I know in our house, organization for us was kind of like minimizing, and I work a lot with my son on that, but we do kind of strategies for him of like, check-ins, creating bins, is this something that he can maintain? And so I have him play a part in that organization and that maintenance and what it looks like, okay, so in this bin for him, he's got all of his superheroes. And in this one, he's got his transformers, and we know that his Duplo blocks go upstai

rs, and his Legos go in this area. And so when there's all of this stuff on the table, "Okay, we need to get the table cleared off. Where does this go?" And so I'm queuing him and I'm prompting him, but he's maintaining the organization system that he's helped put in place, because we worked on that together. So we want to provide organization options and encourage your child to learn what works best for their style. Some might like color-coding folder systems. So minimize, simplify, and have th

ose organization check-in. So this is an ongoing long-term goal. Often, you know, what are you willing to do as a parent to help this kiddo in the support system? And sometimes it's that coordination or collaborating with the schools too, for the kiddo who's got the locker that gets open and there's just stuff falling out. Okay, I'm willing to come and body double, sit with my kiddo as he goes through his locker. But when can we do this, and what does that look like? Or can you help him empty ou

t his locker, put everything in his backpack, and he brings it home, and we'll go through it together at the end of every week? So that maintaining of the organization system. Then the next skill that we talk about is time management. Like I said, the organization and the time management, some people who are really good at it, it's really frustrating to be with those who maybe are struggling with it. And time management, I would say, is a common frustration of just parents in general, 'cause we'

re always trying to get our kids to move and move along, right? Get them to focus on the task at hand. And the reality is that individuals with ADHD often just don't have a sense of time. So the research shows that performance in kids with ADHD in accurately estimating time is weaker. And Cindy Goldrich talks about this in terms of the research that this area just doesn't improve when on or off medication, so you're gonna need to put modifications and environmental supports in place in order for

them to build that skill of time management. And really, it's not that they're gonna build the skill of creating a better awareness of time management, but they're gonna have supports and strategies that are put in place that they can be on time. So some strategies would be like clocks and timers in several locations, especially areas that you noticed that they tend to, like, I dunno, the term lollygag, right? This might be like bathrooms, bedrooms, kitchens, wherever there's a TV, or putting l

ike an end in sight, you know, in the mornings I'll tell my son, "You need to get dressed, and I want to know that you're dressed before your dad gets out of the shower." So dad usually showers first. I get them kind of going along, and then I shower later. So we have that as kind of like a time estimator. So digital clocks are usually best if you're gonna use clocks, 'cause it has a specific number, and it can make time visual. There's also a time timer, and that's kind of what this image is do

wn at the bottom here, and they look like this. I notice a lot of schools will use these, and you can have big ones kind of in the front of the classroom. And like I said, with these strategies, you don't always have to individualize it to the one child in a school setting, but you could do it for your classroom just in general, because we want these executive functioning skills to develop. The nice thing about the time timers, when you set it, if I was to set it for 15 minutes, all of this woul

d turn red, and as the time goes down, we can visualize it going down because now it's turning white, right? (timer beeping) And then the time goes off, then it beeps. So we learned by practicing, asking them to do something in a specific time. If they're a little bit older, they can kind of monitor their own time. Maybe we'll ask them like, "Hey, can you take a look at the clock, and tell me what time it is?" Oh, it's six o'clock, we're having dinner at 6:30, so you've got 30 minutes. You need

to be downstairs. Where do you need to be in 30 minutes?" "Downstairs." "Okay, what time will it be in 30 minutes?" "6:30." "Okay, do you have a timer set on your phone?" Maybe we set reminders on their phone, or whatever it may be to help them kind of cue in and get going with some of that. But we teach them the strategies so that later in life, they learn how to use these and continue going on. The next one develops a little bit more, and we don't see it until like eighth grade, and usually mo

re like the end of high school, early college, and this is goal directed persistence. So this is more advanced, and the reason is we need a working memory, and it's not just a goal, but a lot of skills embedded into one. So we need to be able to set a goal, keep the goal in mind, which is our working memory, and plan and organize to start the task. We have to have task initiation. We have to stick with it, which is our sustained attention, and not be led astray by distractions, which is response

inhibition or impulse control, right? That peer pressure is one we see what that impulse control and response inhibition. Strategies, so contingency with the environment supports, we start development by walking through events, this led to this, so what do you think happened next? Or, what did we miss? We start building this skill by identifying a goal that matters, and working on achieving it and walking through it. And then we'll talk about metacognition. Metacognition is one of the last skil

ls to develop, and teachers will start asking kids to do this in second or third grade. We think of this as like reading comprehension, and it's ones of the last skills to develop, and we start to see that it's developing in the brain around fifth grade, kind of depending on how the brain starts pruning off the synapses that have been developed starting at a young age. So this is the ability to think about thinking or reflecting on the past and exploring our future actions. So it's abstract thin

king in our reading comprehension. Often we'll see individuals with ADHD, when they're struggling academically, reading comprehension, writing, and math, because of the working memory, the multiple step procedures, keeping that in mind, and knowing what kind of happens next, the reading comprehension, the ability to think about thinking and what's coming on next. And so we noticed that more as they get a little bit older, so we might encourage things like scratch paper for them to, to kind of jo

t down if they're reading a bigger book. Like as they go, they're gonna write down the name of each character, and then as the plot unfolds, what are key things that they know about that character, and timelines, and kind of where that comes in. Some strategies that you can do at home are reading and exploring comprehension. So maybe you read a section and you explore with them, what do you think's gonna happen next? Or how do you think this character is feeling? The nice thing about reading at

home is there's lots of amazing books that you can do at home that also talk about emotion regulation. And so then you can process with them like, "Okay, so how do you think the character was feeling then? And if they were feeling that way, how do you think that people around them were feeling? What do you think they could say to themselves if they were feeling frustrated? And what do you think that they do next? Or what do you notice that they did next? What could they have done instead?" So th

e reading comprehension and development and reading at home, you can also explore emotion regulation, and kind of work in all those areas with the working memory too. So when we work on metacognition and reading comprehension, you can tie in a lot of things with reading, and in therapy, we call this bibliotherapy. A lot of times you can use social stories, and those kinds of things. So it's really that idea of like what plus why equals what to do next time. So talking through events, what happen

s? Why did you respond this way? What do you think you could do next time? Those kinds of things. So, I know I talked really fast, because I was trying to give you as much information as I could in a really short amount of time. I think in the past, when I've done these presentations, they're about two hours, and I try and do a little bit more interaction, but in order to give you just kind of the starting framework of ADHD and executive functioning, I had to kind of drill it out really quick. S

o I know it's overwhelming. If there's areas that you really want to know more about, please let us know in the chat below, and my encouragement to you is really just to start where you are with what you have. And this is a quote by Jim Rohn, and to be curious, get to know the child, and wonder why these things are going on for them, observe from a nonjudgmental stance, be specific on goals, and use praise with immediacy. When we talk about praise, it's really praising the effort, the strategizi

ng, the work and the persistence children put into their accomplishments. This may allow for fuller recognition of their achievements, and lead to greater mastery oriented behavior than criticism ever will. So, some review of the big challenges. One to keep in mind with ADHD, individuals will have a slower processing speed, so they may need accommodations and time to allow them to process what's going on around them. Next is the working memory. Notice where the child may need extra support, and

add in visual cues and reminders. The third one, difficulty regulating attention. So we want to reduce distractions when possible, and encourage mindfulness with just one task at a time. Fourth, impulsivity. Anticipate when it may happen. So identify environments, people, and times that they tend to be a little bit more impulsive, and make a plan, have cues and reminders to stop and think, and do what you can to make them aware of it, and responsible for their actions. The fifth is a sense of ti

me. We want something to measure time, making it visual. And then deficits in emotion regulation, learn to model and help coach your child on recognizing emotions along with regulating them. So some classroom modifications and accommodations, you can find a lot of information on ADDitude Magazine. They focused just on ADHD. There is a link in the handout on there that talks about classroom accommodations for schoolchildren with ADHD, and then you can send any questions or feedback to me, and we'

ll have about 10 minutes here to kind of go through any questions. And I'd love to hear back, you know, what's one action step you can take as a result of what you've learned here today, and what was helpful, what would you like to know more about? So we'll go ahead and open that up for the last 10 minutes. - All right. Thank you, Rachael. Chanel asked a question about assisting young people with ADHD with social integration, including professional integration, and in the labor market. - Yeah. T

hat's kind of a big question, so to unfold it, I think some of it is just looking at where are there areas of struggle? So when I look at that, I like to youth pick Dawson's executive functioning assessment, because they can take that, and then we know exactly which of the executive functioning skill they may struggle a little bit more than individualizing those goals and strategies for them. So in the labor market, I guess I'm wondering more specifically, which executive functioning or which ar

ea you'd like to focus on? - Wendy asked if you know where we could find a list of books that might be helpful to read with our kiddos? - Social books that you would read your kiddos for like emotion regulation? Julia Cook has a lot of really great books that I like. I found some really nice books through Usborne as well. If you want to email me that question too, I can send you a list of books that I've kind of put together that I enjoy, and I'd be happy to pull that in. I know Usborne has some

really great activity journals that talk about different emotions, and how they work through, as well as giving different activities and prompts that go through that. Julia Cook, again, has some really great emotion regulation books. So it kind of depends on which emotion or feeling you're looking at, and then I could give some more specific books suggestions, but Amazon has some great ones too. - Jessica asked if it's in part genetics slash family, how might ADHD parents or families manage tog

ether? - Really, I think if an individual is referred in for counseling and they meet that point where they're struggling, it has to be a family engagement and family involvement. If you want to see changes in a child with their ability to regulate their emotions and their behavior, the fastest way to do that is to change the environment, so you need to make accommodations within that environment, put in supports and structures within the environment, and notice where they're at, and where we wa

nt to see that skill develop. So we set these kind of mile markers or stones, and some of that is providing education to the parents, helping the parents understand areas that maybe this is an area that they're clashing together, and so we make those family goals as well as individualized goals, collaboration within the school, because again, it has to be that immediacy, and reframing and accommodations that have to be put into place in order to see that growth. - Okay. Heidi asked, is it common

for kids who have ADHD to need both medication and therapy, or is therapy just as effective in some cases? - Kind of repeating what I said earlier, you have to have the environmental changes and accommodations, and sometimes that helps with the skill development. When you think about medication, like I said, there's deficits in the norepinephrine, serotonin, and dopamine, and the inconsistency of the firing in the brain. So really what happens when you're using a stimulant is that it's stimulat

ing that firing in the brain. Sometimes you're usually using medication that'll help with like serotonin or dopamine, and so it's boosting the areas that they are already having the deficits. Medication isn't always a necessary thing, and what I do as a provider, because I'm not a prescriber, is I process with the parents any questions or concerns that they have. And if the individual is working on this skill growth, and we're still noticing that there's some struggle, even with the accommodatio

n and things that we're putting into place, I would put in a referral to psychiatrist, or to the PCP to just explore options for medication, to see what's out there and if it's a fit for them or not. But I try not to sway people one way or the other, but just to kind of process with them what the benefit is. And sometimes when you look at medication, it's really that this individual is struggling, and the pot is kind of always boiling over, and the medication helps it just to kind of get it to s

immer, and then they can engage in learning those skills, and skill development. And so now their pot isn't always just kind of simmering, boiling up, but then it's more manageable for them. - We've had a few questions about the books that you've mentioned, the one by Dr. Kenthworthy, I think, and the ones that you recommended on the earlier slides. - Yeah. So this is one of the books. You can get this on Amazon. It's easy for like audible, as well as a physical book. This is Peg Dawson and then

Richard Guare's "Smart But Scattered." She also focuses on "Smart but Scattered" looking at adults, teenagers, and she has some newer books as well talking about "Smart But Scattered" executive functioning in the classroom, giving some information about that. The nice thing about her books is that she also talks in the one for schools about IEP's, 504's, as well as executive functioning assessments would be in there. For parents, I often refer to this one, "Eight Keys to Parenting Children with

ADHD." This is by Cindy Goldrich. She also wrote a book with her daughter for classroom, and I just want to make sure that I give the correct name. I think it's "Executive Functioning in the Classroom", is what she refers to it as. And then another one for in the schools is "Managing ADHD in the School," all of these, like if you Google, or if you Google or you go into Amazon and you put Russell Barkley in, a lot of his books will pull up. You hit the Cindy Goldrich, this one, and then the book

that she co-authored with her daughter, which I think is just an amazing bonding experience that she wrote a book with her daughter, her daughter works, I believe, in special education within the school. And so they kind of tied the two things together, or Peg Dawson. A lot of her books will pull up as well. Those are the books you're referring to, right? I think. - I believe so. And then looking at some of the feedback that we're getting in the comments. Kayla said that one action step I can t

ake is sharing this information with teachers, and equipping them to better manage their interactions with students. When working with students with ADHD, I will help them practice time management, emotional regulation, role-play impulse control scenarios, et cetera. I believe I saw one other question. - There's one other book too, that I really liked. This is called "365 Ways to Succeed with ADHD," and it's by Laurie Dupar. Again, this one you could find on Amazon, I think you could find anythi

ng on Amazon, I don't know. (Rachael chuckling) - Okay, one question that Anne asked about IEP's. She can file an IEP, but they don't really get used by teachers, because there are just too many kids. How can I get the school to actually utilize accommodations? - Advocating. I think circling back to it asking if you have a release of information, and you're working with the kiddo or your a parent, referring back to what's in the IEP and following up, what are the modifications and accommodations

that are happening in the school? I have a lot of (indistinct) teachers in the stands, like when I'm working through those, I'm working with maybe one or two in a setting, sometimes the most would be five in a group setting. But when you're working in a classroom, you've got one teacher to 30 kiddos, and remembering the statistics, sometimes you've got three kiddos who are struggling with ADHD. So in a classroom setting, making some of these accommodations just in general, and you're not necess

arily individualizing it, but you're looking at, okay, how can I help this classroom develop these executive functioning skills overall? It's kind of making your job a little bit easier, and maybe it's looking at the preferred seating, and what does that look like? Yeah, I think with the accommodations within the school setting, if there's an IEP in place advocating that that IEP is utilized, and continuing to follow up and exploring what are accommodations, what are the barriers that are gettin

g in the way of these accommodations happening? And as a parent, also kind of following up with a collaboration with the school of what is it that you're willing to do as the parents help too? - All right. Well, thank you so much, Rachael, for putting together this wonderful presentation. I know I learned a lot from you today. We greatly appreciate your time. If you have any questions that we didn't get to, Rachael's nice enough to give out her email so you can send any questions and feedback to

her there. And thank you to our audience for being here today, being present, and for asking some really great questions. Please don't forget to complete the survey linked in the chat box, and check out our YouTube channel. We are Strengthening the Heartland.