What Does It Mean To Have ADHD?

Attention Deficit Hyperactive Disorder (ADHD) is a developmental impairment of the brain’s self-management system known as executive functions. This disorder is one of the most commonly misdiagnosed disorders affecting both children and adults. In this webinar, we will delve into what ADHD is, the signs and symptoms, as well as the reasoning behind these misdiagnoses. We will cover the role that gender stereotypes play in the rate at which boys and girls are diagnosed and the impact it can have on their self-esteem and mental health. We will also talk about the different ways ADHD can present itself in children versus adults and why it is not uncommon for individuals to get diagnosed later in life. Lastly, we will cover some of the different skills and treatment options an individual can receive to help manage their executive functioning impairment.

Eric Deibler, M.S.Ed., Psy.D has been a school psychologist for 30 years, holding a master’s degree in school psychology and a doctorate in clinical psychology. He has worked in a variety of settings serving children with mental health needs, including public and private schools, self-contained special-education facilities, residential treatment facilities, and psychiatric inpatient and outpatient hospital programs. Dr. Deibler recently retired from the Burlington County Special Services School District, where he served as a psychologist for 19 years. He is currently a consultant for his wife’s practice, the Center for Emotional Health of Greater Philadelphia (CEH). He specializes in clinical diagnostic work and therapeutic services for children with severe mental illness.

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0:05 OK, welcome. 0:09 Good evening, and welcome. Thank you so much for joining us tonight for the webinar. What Does It Mean to Have ADHD presented by doctor Eric …. My name is Katie Delaney. I am the Family and Medical Outreach co-ordinator at the New Jersey Center for Tourette Syndrome and Associated Disorders. I will be your facilitator for this evening. 0:31 Now, before I introduce doctor …, here are the housekeeping notes. All participants are muted. If you have any questions, please type it in the bottom of your question box, and click Send. 0:43 If you have questions after tonight’s session, you can post your questions. 0:49 On the Wednesday webinar blog, which is Access from our homepage at WWW dot N J CTS dot org. 1:00 Under the Heading Programs, this blog will be monitored for the next seven days. 1:06 The New Jersey Center for Tourette Syndrome and Associated Disorders, its directors, and employees, assume no responsibility for the accuracy, completeness, objectivity, or usefulness of the information presented on our site. 1:21 We do not endorse any recommendations or opinion made by any member or physician, nor jui advocate any treatment. 1:29 You are responsible for your own medical decisions. 1:32 Now, it is my pleasure to introduce our speaker for this evening, doctor Eric dive lawyer. Doctor … has been a school psychologist for 30 years, putting a Master’s degree in school psychology and a doctorate in clinical psychology. 1:47 He has worked and a variety of settings serving children with mental health needs including public and private schools, self contained outpatient hospital programs. 2:03 Yes. 2:05 All right, self contained Outpatient Programs, doctor …, recently retired from the Burlington County. 2:15 Special Services School District, where he served as a psychologist for 19 years. 2:21 He is currently a consultant for his wife’s Practice, the Center of Emotional Health. 2:27 Greater Philadelphia, C E H, He specializes in clinical diagnostic work, and therapeutic services for children with severe mental illness. We’re so happy to have you here tonight, doctor Di Blair. The floor is all yours. 2:42 Thank you very much. So, yes, I’ve been in the field for over 30 years now, licensed clinical psychologist and certified school psychologist. And I’ve worked in all those settings that were just mentioned. And one of the things that has come up and most frequently is the topic and diagnosis of attention deficit hyperactivity disorder. 3:01 And this isn’t surprising, because it is the most common by most statistics that you look at, most common of the four most commonly diagnosed mental health conditions in children’s ADHD. 3:14 That the number one, anxiety being number two, behavioral problems, although that encompasses a lot of different diagnoses, Number three, and depression is number four. 3:23 Now, this, these conditions can, you can have more than one of them. So it isn’t like they’re there for separate things. 3:30 In fact, they often commonly Coke, but we do see this every day in all of these sets. 3:35 And one thing that has been consistent from the time that I started my first graduate program in 19 89 until today is that ADHD is commonly misunderstood by practitioners, by parents by a lot of different people. It’s a much more complicated diagnosis. It’s a much more complicated condition than many people realize and I had trouble coming up with a good title for this. I usually want to come up with something pithy that that kind of encapsulates everything. 4:10 But really what I want to get across is that attention and hyperactivity are often the least of the issues with ADHD. 4:17 And we’re going to be talking about what the real issues are like, and what it’s really like to experience them, and to deal with it. 4:25 So what we’re gonna be talking about tonight, we do have to go over some of the diagnostic basics. I mean, I know these are the, the diagnostic criteria are very commonly available, but there’s nuance to them that isn’t always understood. So we’re gonna go over them as much as we need to, but then we’re going to move on. We’re going to talk about the concept of the ADHD iceberg, which will be clear once we see it, and we’re really going to focus on the idea of executive function. And this is the main thing that’s going on in ADHD. And this has become clear over the years. We’re now, it seems like, this is the primary issue that’s going on with ADHD. And you have to understand this if you want to understand the condition itself. 5:02 So once we get to that, that’s, we’re going to talk about what ADHD really looks like and then how you can use these things to work with your children or with yourself. 5:13 So first, the diagnostic criteria. Almost all of our criteria and our book, the DSM, the Diagnostic and Statistical Manual, for Mental Disorders, they follow a similar pattern where they’re going to demonstrate, like, here’s the main thing. Here’s the criteria. Has to have a negative effect. So here’s the lows for ADHD. 5:33 So ADHD, people with ADHD show a persistent pattern of inattention and or hyperactivity and impulsivity that interferes with function or development. So you have to have that component. It has to interfere with something important. 5:49 Now they’re separated into groups of symptoms. There’s inattention and there’s impulsivity hyperactivity. And they follow a similar pattern. So from the first group, depending on your age, you either need 6, 5 or 6 of symptoms. six, if you’re under age 16 or under. Only five is your 70 or older. They have to have been present for at least six months. They are inappropriate for your particular age or developmental level. 6:16 one way to think of this is, a child who is five years old does not and cannot pay attention the same way. A child who’s 15 year, old, 15 years old. So it has to be out of proportion, or otherwise inappropriate. Or concerning for the age. 6:32 So here are the symptoms. Remember, He needed 5 or 6 of these failing to pay close attention to details careless mistakes and in trouble holding attention to tasks or activities doesn’t seem to listen. It doesn’t follow through on instructions fails to finish things. Has trouble organizing tasks avoids. Dislikes are reluctant to do tasks that, require mental effort over a long period of time. Meaning, you know, like, maintaining focus for long enough. They avoid activities like that, like doing homework, doing lengthy complicated tasks, they avoid. 7:07 Often loses things that are necessary for tasks. Is easily distracted, and is often forgetful. 7:13 The next group is hyperactivity and impulsivity think. It’s still going to be the same format. You need six or more symptoms appear 16, 16, or older, five or more of your 17, 16 or younger. five or more. 7:26 If you are 70 or older, same thing, they’ve been present for at least six months, that that is disruptive and inappropriate for your developmental levels. 7:36 So the symptoms here are fidgeting, or tapping with hands, or feet squirming in your seat, or inappropriate Access movement, part of leaving seats in situation where it’s where remain seated is to be expected, runs about climbs in situations where it’s not appropriate, like say, in a classroom, climbing over desks or filing cabinets, things like that. 7:58 Unable to take, unable to play, or take part, in leisure activities, quietly, and that’s, you know, like a volume that is excessive for age. 8:07 Often on the go, acting as if driven by a motor, talking excessively. blurting out an answer before the question has been completed, difficulty waiting for your turn, and interrupting and intruding on others and games or or other kinds of situations. 8:20 Again, none of these behaviors are unusual what you’re looking for, Something that’s excessive for the age and disruptive. 8:27 So beyond that, there have to be a few other criteria. 8:31 You have to have shown some of these symptoms, at least before the age of 12. 8:36 So, you can diagnose people who are older, but they have to have shown symptoms before they’re 12. So if you have no symptoms throughout childhood, and then you’re reporting these symptoms at 18 years old, you’re gonna be looking into different conditions and ADHD is not going to apply. 8:50 The symptoms have to be present in two or more settings to, can’t just have trouble at school, and not at home, or vice versa. So parents may report things at home, No, trouble at school. If it isn’t in two places, it’s not going to qualify. 9:04 There has to be evidence that these symptoms are clearly interfering with, or otherwise, negatively, affecting the quality of function in one or more settings. So, it has to be having an impact. It has to be having a negative effect on things that they want to or need to do. And the last one, and this is common with everything, the symptoms aren’t better explained by something else, Like a medical condition or another disorder that could have attention. You know, that’s, that’s our criteria for rule out other causes. So if you meet all of those things, you’ll meet the diagnosis of ADHD. And I think a lot of people will stop at that point, thinking that they do understand what’s going on. But it doesn’t necessarily cover. 9:44 Last word on this diagnostic point. 9:47 The number of symptoms you have in each category will be what Differentiate the subtype of ADHD. 9:55 So, if you have enough symptoms in both areas, it’s like 5 or 6, in each of those areas and attention …, you’re gonna get what’s called a combined presentation. This is probably the most common one, and often the one that has the most behavioral issues associated with it. 10:11 If you have only you know, enough to qualify for an inattentive part, but not the hyperactive part, you’re gonna get predominantly inattentive presentation. 10:20 If you have the reverse, you’re gonna get predominantly hyperactive impulsive presentation, and you can see all of these. 10:27 one thing that’s worth thinking about, you’ll hear people say ADD versus ADHD, that is about 25 years out of date. They haven’t talked about that in a long time. They no longer call it ADD. 10:39 No without the hyperactive with main thought is that impulsivity is by far more more likely to be in any of the presentations. And the predominantly inattentive type may actually be a different condition. They’re not really sure about that, but it is interesting that the medications you get for this are more effective in general for the hyperactivity and impulsivity and less. So for the inattentive part, so a lot of times people have hyperactivity and impulsivity. They get a better effect from medication and perhaps made from the inattentive type. 11:14 Now, this, this is a very commonly used metaphor. These days, the ADHD iceberg, and this particular one was taken from Jonathan Wolfe and his You Time Coaching Practice. 11:29 This is a particularly good one, but this is popular because it really does reflect the idea of what’s going on, an ADH, the whole idea of the iceberg. And, there’s things that are visible on top, and things that are invisible below. 11:43 So, in this metaphor, the top of the iceberg parts, as you can see, is the behavior. 11:49 This is the stuff that is acting out impulsivity and the poor focus. The other things are the things that are more experienced by person, and they’re less easy to observe that these reflect more along the lines of what is going on with the purse, difficulties and emotional control. Problems with stress tolerance, difficulties, planning, prioritizing, organizing, starting tasks, being able to change tasks when you are changing demands change, being able to keep things in, your memory, managing, time, all of this kind of stuff. 12:23 What I’m going to be making a case for here is that this is the area that is the most significant. This is the area that is most impacted. 12:30 This is the area that is actually the least visible to anybody else. You can see the behavior, but you can’t see the person’s inner mental process. 12:42 This brings us to the idea of executive function. 12:45 Now, this is somewhat theoretical group of, of organizing principles in the brain. 12:52 Although, like, over the years, the evidence has gotten stronger and stronger, that this is an actual, this is an actual thing. It isn’t just an idea. 13:01 It does seem to be a system in the brain that helps control actions. And I like this particular description. There’s many of them. But this is a nice, short one. 13:10 And this is from the Center on the developing child at Harvard University, and that is not a typo. 13:15 It is centered on the developing child not center for the Developing Child or Center for Child Development. That is the name of the pit. It’s a campus wide program of different disciplines, but this is their definition that they put on their website. 13:29 Executive function and self regulation Skills are the mental processes that are now that enable us to plan, focus attention, remember instructions, and juggle multiple tasks successfully. 13:39 Just as an air traffic control system at a busy airport safely manages the arrival and departure many aircraft on multiple runways, the brain needs this skill set to filter distractions, prioritize tasks, set and achieve goals, and control impulses. Now, I want to point out one thing they say here, this is the one part I wish they had maybe phrased differently. Juggle multiple tasks. 14:01 Makes it sound like multitasking. But that’s, that’s not the same thing, but they really mean is, is understanding what needs to be done next, you know, out of many options, and prioritizing what you’re doing. Which is definitely a different thing. And we’re going to talk a little bit about multitasking, too. 14:15 So these executive functions The research generally supports that. 14:20 There are seven basic executive functions. 14:24 They’re self-awareness, and, in this sense, they mean, it’s, it’s a conscious awareness of what you do, so that you know what you’re doing, you know how it’s going, you’re evaluating what is happening in yourself with what you’re actually doing. 14:38 There’s the concept of, in addition, which is the ability to control impulses. Self restraint basically cannot do behavior. 14:46 So you can see how that plays into impulsivity, the idea of not acting out when you think of something. You will give yourself some, some. 14:55 Little bit of room before you act, non-verbal working memory, and that is pretty much what people think of when they think of short-term memory. 15:02 It’s the idea of actually holding, um, mental images, but it also involves things like a sense of time, anticipation of future goals. There’s the idea of how much time has passed, and how much time is remaining. Verbal working memory is really a very concrete skill that’s having a certain amount of, of verbal information, that you can hold in your brain for long enough to work on, and maybe to transfer it into long term memory. 15:31 And the example that most people use for this is that, they believe that you can hold basically seven bits of unrelated information, like seven numbers, seven letters That are, you know, that are not related to each other. 15:44 If you can make them related to each other, you can make them into one good information. But something like seven numbers, you can hold for a few seconds and that is the, the genesis of the seven number phone number, because they figured that was the most that people could hold in their brain for long enough to be able to write it down. 16:01 So then they came up with area codes. So like, a separate thing, you know, that’s, that’s another story. 16:06 But that is just like, the ability, like, how long can you hold something in your head before you forget? What’s here? 16:13 Emotional regulation is, can you modulate your own emotions? Can you hold back a reaction to can you hold back and angry reaction? This is a very long and complicated subject in and of itself will try and touch on it if we have time. But he is part of executive functions. 16:31 Motivational regulation is exactly that. Can you keep yourself working on something? 16:36 It’s internal motivation, self directed, internal stimulation. Can you do it without having somebody tell you to do it, and planning and problem solving? 16:45 But in this sense, it means, can you have a mental plan, can come up with a plan, that you can evaluate with that self-awareness and realize, OK, is this working? Do I need to change something? Can, can I fix this in some way to make it better? 16:58 So all of these functions are absolutely vital to being able to do things within a timeframe, to being able to do things without guidance. And to be able to stay organized and on task. These are the functions that are impacted in ADHD. 17:21 So I want to point out something here and bring back to this slide, Just in an attention alone, what I did here? 17:27 Was I highlighted the symptoms of inattention that involve executive functions. And you can see, just from these highlights, every single one of them is involved in at least one of those major executive functions. 17:42 So trouble holding attention, does it seem to listen, not following through on instructions, organizing tasks. These are all direct results of executive dysfunction. 17:53 So what is ADHD? 17:58 Really luck. 18:01 The first thing I want to tell you about before, I’m going to tell you a lot of the stories here, but the first thing I want to tell you about is that when we go through all these things, the thing to remember that one of the most important aspects of executive function is self-awareness. 18:16 So, one of the things that’s impacted in this, is that people are generally less aware of their executive functions. 18:25 So they’re not necessarily aware that they’re not doing these things well, and we’ll explore a little bit as to why. So, let’s look at these different aspects. If you have these deficits in executive function, what does it look? 18:38 The working memory problem. 18:40 If you just look at verbal working memory. 18:43 The idea of catching information, holding it in your short-term memory for long enough to do something with it, to write down, and put it into memory. 18:52 If you’re weak in that, you will miss things. 18:55 And once something is forgotten, it has gone. 18:58 When, from short-term memory, you’ve basically lost. You don’t know that you’ve necessarily forgotten. 19:04 So, when you have someone who is like, hearing the whole bunch of things, like, you have to do this assignment. It’s on this page, with maybe trend right down, and being distracted. They missed something in short-term memory. 19:15 It’s gone. 19:16 So, it isn’t that they can’t do the assignment, They may not have gotten it. 19:20 They may not remember that you said, so, at that point, they’re missing something that there is no way they can retreat, because if it is lost, it is gone. 19:30 So we have that issue. 19:32 The positive illusory bias. And there was different ways that I used to say this in the past, because there are certain that, this has always been an issue, but this is maybe the best way to look at. The positive illusory bias is something, you know, will mostly you use this when you’re talking about kids. And what it means is that kids over overestimate their ability to do things that they’re actually weekend. So they overestimate their ability to perform something well, to do a task, to do well on test. And this is demonstrable through, through actual research you can show. Kids overestimate their their weaknesses. 20:11 Now, that’s nothing, there’s nothing abnormal about that. That’s just how kids are. 20:16 And they think that this is, this serves a lot of helpful functions that if a child believes they can do something, they’re more likely to try, they are less likely to be anxious about how something will turn. 20:29 Um, when they do try it, if they fail, they are more likely, at this point, to say, like, Well, I’m sure I can do that. 20:37 So it actually can shape motivation. 20:39 It can shape behavior, can work out well, so being realistic may not help them that much, Thinking that they can do stuff when maybe they’re not that great at. It. May actually get them to try it and learn it. 20:49 So it is not viewed as a negative thing. But there’s a very, very important thing about people with ADHD. 20:56 Kids with ADHD haven’t very different positive, illusory bites. 21:02 They can show that they, they have a much more pronounced sense of this than other kids, kids who don’t have ADHD. 21:10 So they think they’re significantly better at the areas that they’re actually the weakest in. 21:16 So, it’s a bigger bias issue. 21:19 Now, that may not sound like it’s a difficulty, but the problem is, with ADHD kids, they’ve shown that this positive illusory bias doesn’t enhance their motivation. 21:31 It doesn’t keep them going for longer, it doesn’t change their performance in general. They think they can do these things they’re weak at, but it doesn’t change how they do any of these things. 21:42 So, they don’t necessarily, another way to look at it is, they don’t believe they have these weaknesses, for the most part. And we see this when we interviewed kids, when we’re doing psychological assessments, you know, they, you know, we interviewed parents, would give them different test measures. Or do they Have this difficulty in this difficulty? 21:58 Many times, kids with ADHD, they will say that they don’t have problems with it. They said, No, I don’t have any promising research. 22:06 They’re not really aware of it. 22:08 So this is part of the reason why kids with ADHD, they’re positive. 22:14 Illusory bias doesn’t really change, even when they’re given evidence that it’s wrong. 22:20 So, they may think, I, know, I pay attention very well, even when you can show them that they do have difficulty with it. It doesn’t change this feeling. And, this is going to become a thing. 22:30 So, it’s, it’s reflective of the deficit that they have trouble seeing, and the reason they have trouble seeing these things is the ability to see these things, is an executive function. So, that part is not working the way that it should. 22:45 And I’m gonna bring up one of my favorite studies, Mostly because it has a follow-up, I’m not sure how old this study is. 22:53 It’s many decades old Day, told us this. 22:56 When I was in driver’s ed in high school, and that was 40 years ago, they brought up the idea of, the better than the average driver. 23:04 And it’s a social psychology experiment. It’s not clinical. It’s more from the academic world, And they would say that, like, most people rate themselves as a better than average drive. 23:15 Which, even if you don’t know statistics, you know, that can’t possibly be the case. Most people can’t be better than average, because most people are average, but most people think they’re better than them. And for a long time, they use this, as an example, of saying, Well, people have an overinflated sense of their builds. People have basically an adult version of the positive illusory bias. 23:37 They think they’re bad because they, you know, they, you know, whatever, like, a self centredness or something like that. 23:44 However, nonetheless, 10, maybe 15 years, Another group of researchers did follow up on this study. 23:52 And they tried to say, why do people believe they’re better than average in this? 23:57 What they found was that people who make mistakes, when they’re driving, people who miss red lights, people who cut somebody off, people who didn’t stop at a stop sign. 24:10 They don’t know that they did, that, they didn’t see, that’s why they went through the life, But that’s why they drove too close. 24:16 They were unaware of it. 24:18 They are aware when they notice other people making mistakes. 24:22 Presumably, Damien’s may miss other mistakes also. They’ll see someone else go through like this, I can’t believe they did that. But as far as they’re concerned, they never did. 24:31 This is a very important concept. 24:34 They can’t fix mistakes that they don’t know that they make. 24:37 They rate themselves higher because they didn’t see the stuff that they did. That’s why it happened. So it isn’t a bias to think, Well, I’m just inherently better than other people. They don’t know that they made these mistakes. 24:48 This is kind of a central theme, NADH. 24:51 They don’t see these things when they happen, because that is part of the executive function. Ability to review these things as they happen. 25:01 It’s also we’re talking about I know I said, I’d say something about multitasking. 25:05 And I said, The multitasking myth, which we’ll give you a hint where this is going. 25:10 For as long as they were able to do cognitive research, they were generally able to show that people can only focus on one thing at a time. 25:17 They can basically do one thing, and then, if they try to do something else, their attention is divine. 25:23 But multitasking has become a social buzzword and, know, people who are doing multiple things at once, the idea of talking on the phone, while also typing an e-mail, or texting people, while you’re in a conversation at dinner and doing these things like that, and that this was something that many people valued. They said, like, I can do all these things, and you have to multitask. That’s what my job requires. 25:49 So Stanford University in 2009, tried to do a study to show about social as well, about technology use. The idea of these kinds of tasks, phones, and screens and all this stuff at the same time. They were trying to find out what made people good at this since this was being touted by so many people. And they had a group of college students that they determined were. 26:12 Hi media multitaskers and low media multitask, because people who said, no, I’m really not any good at that. So they tried to run tests and said, like, what makes these? 26:22 What makes these other people better. 26:26 The short version of it is, they ran through three separate different kinds of cognitive tasks that multitasking and no, and requiring, using differential attention, all this stuff. And they found that the people who are reporting themselves as high multitaskers were much worse. 26:43 In every one of those tasks, in every way that they did it. 26:46 Then the people who view themselves as not good, and that the longer they went through these tasks, the worse they became. 26:55 The the one of the authors basically said these people, they were suckers for distraction that they were distracted by. 27:04 The interesting thing is, of course they found at the end, it’s like, well, nobody’s good at multitasking and people who think they’re good at multitasking are actually Really bad for the most part, but again, here comes the theme again, They’re unaware that they’re bad at it. They feel like they’re being productive, They feel like they’re paying attention. 27:24 Now, if you look back at some of these things, like we looked at, one symptom under gained attention was like, you know, difficulty with, or avoiding or disliking things that require sustained attention, which is something that we’re gonna find with, with attention, difficulties, and executive dysfunction and jump like that. These things are hard. So sometimes people will like, go from task to task, with a distraction focusing on this focusing. And it feels like paying attention. 27:50 It is easier than sitting down and reading a technical manual. It’s easier than sitting down and doing something that’s hard, like that. And they’d say, like, Oh, I’m here. I’ve got this. I got this, I got. 28:01 But they don’t, they’re actually missing a great deal from thing to thing, but they’re not necessarily aware, but it feels like attention. 28:08 Now, if any of you have kids, or when you were a kid, or if you’ve just been around kids, you’ve probably come across this before. 28:16 Where somebody’s tried to do their work, and like high school students doing the work and saying, well, I pay attention better if I have a show on. 28:26 Or I pay attention better, if I listen to music. And I can text my friend when I do this. That helps me pay attention. 28:32 Know, it does take almost universally, it does not think that it does, they think it feels like pain, but they’re missing things. And if you put this stuff together with the working memory deficits, don’t know necessarily what they’re missing. 28:46 It just feels bad, so they feel like it’s attention. 28:50 So multitasking is pretty much everybody does worse with. Now, I know I said something before about multiple tasks managing multiple tasks within Harvard definition. So let’s do a little experiment here. 29:05 I use the same one all the time. I like it. 29:07 So what I want everybody to do, anybody who’s listening, I want you to pay attention to what I’m saying. 29:14 I’m going to tell you to focus on some things. 29:17 The first thing I want you to focus on is your shoes if you’re wearing shoes. 29:26 If you’re not focused on socks, if you barefoot, think of this feeling of your foot on whatever surface that it’s on. 29:36 Pay attention to them. 29:39 Notice how it feels. 29:41 Notice where it’s tight, or where it’s loose. 29:48 Notice your clubs. 29:50 Any article close? 29:53 A watch, Nicholas Belt shirt. 29:58 You can feel it on me. 30:01 Maybe some of it’s uncomfortable. 30:04 Maybe some of it is itchy. 30:10 But what I’m guessing is, you probably weren’t thinking about any of these things, until I told you this, unless they were painful or something unusual. 30:21 In fact, I’m guessing that while I’m talking, if you’re listening to what I’m saying now, you’re thinking less about those things you’re thinking less about, how you shoes? 30:30 This is what it means to manage multiple tasks. 30:34 Your nerves are constantly sending these sensations to you. 30:39 If you just noticed your shoes, the feelings, shoes on your feet when I mentioned it, you are still getting those same signals to your brain. 30:46 But your brain is inhibiting those sites and allow you to focus on something else. 30:52 That’s what attention is the ability to push down irrelevant things. 30:58 The other thing that I like to do is say, listen to the sounds around does your computer have a fam? 31:03 Can you hear it? 31:06 Can you hear the HVAC system in your room? 31:08 Are there others, other background sounds? 31:13 Maybe you didn’t notice those, until I said, it’s the same thing. 31:17 Your brain gets all of these sources of information, all the time, has to direct conscious attention to one thing at a time. 31:25 So these things get pushed there, unless that system doesn’t work very well for you. 31:32 And then, your attention is going to be divided amongst things that distract you. 31:36 The brain has a harder time focusing on what is necessary, well, what’s real, and no brain can’t multitask. 31:45 So, we know that if you’re focusing on this, or if you’re trying to text somebody, when you’re, when you’re also talking to somebody else, the attention can’t serve two masters, it has to look at one. It has to focus on one thing. 32:00 So the other thing is either viewed as irrelevant, or if you can’t do that, and you’re distracted, that’s what these things feel. 32:09 So people who are distractible, a lot of times, this is one of the things, The way that they experience it. 32:15 They can’t necessarily automatically maintain this focus. It takes effort. Focus may drift is something else that needs to be pulled back. 32:23 I’ll give you one thing. That’s another another great example and probably never thought of before, if you’ve ever been at a party. 32:31 And there’s a whole lot of people talking, and you can focus on one person and hear their conversation. 32:37 That is focused attention, That is executive function. That’s a very specialized function in our brain heads. Computers can’t do that. 32:46 We have speech recognition programs, but they can’t pull out one voice when multiple people are talk, but we do it on Mac, mostly unless you have ADHD. 32:54 And then you may find that very difficult to sustain attention in a room with a whole lot of people talk, like focusing on one person, may be difficult or even impossible to do, at least to do for very long. 33:06 So, now, we have a sense of what some of these things feel like. 33:11 Let’s talk about what it looks like, how it can affect you. 33:17 The procrastination problem is my favorite, because we see this all the time, where, say, like, you know, again, applied to students. 33:25 So you give this, you give an assignment to students, and they say, Well, I have week to do this, that’s fine, I don’t have to start this now. I’ve got all this time ahead. 33:35 Weakest luck. So, I’m not gonna worry about it today. 33:38 I have all these other things I want to do. 33:40 I’ll started tomorrow, and then tomorrow comes, and it’s like, just took, that’s due next week. 33:45 Don’t just worry about, I’ll do it later, And then the next day, like, it’s coming up soon, but that’s fine. 33:53 It’ll be late recruiting the next day comes and say like, well, I should probably start something, but why do I have to go to practice? And I have this one, I’ll start to learn. Then tonight comes around and you say like, well, it’s late down and tired. I don’t want to do, and I’ll do it tomorrow. There’ll be more focused tomorrow, you get the pattern here, It goes up to say, like, well, started after dinner on, started before bed. Like, oh, I don’t have enough time now. I can finish it, it ends up, like, where you’re rushing, rushing, rushing, and maybe do a very poor job that. Maybe don’t finish if you don’t even started. 34:25 And then you go in the next morning and you have an incomplete saying, well, you don’t have the project at all, or maybe even left at home, and then you’re upset. And everybody’s upset with you. You had all week to do this, and you didn’t do it. And then they tell you, like, you have to plan better, and you get you more organized and thinking. Yes, I need to be more organized, and I’ll, I’ll plan better next time. 34:46 But they won’t, because that’s part. That’s the part that isn’t work. They’ll have that experience. But that feeling of, I can do it later, Never goes away. 34:56 It never changes. It always seems like there’s enough time. It always seems like that you can easily put forth the effort, regardless of the experience that you have. 35:07 So you end up with people upset. You end up being upset with yourself. 35:10 Perhaps you end up with this issue and then being faced with the consequences that you don’t learn from, because the ability to do that is the thing that’s effect. 35:20 You know, the ability to say, How much time do I need to do, how much effort doing? 35:24 You know, Oh, this is going to take six hours. I better start now. That doesn’t happen naturally. 35:29 So, people end up making the same mistakes over and over again and feeling bad about themselves often because they told people will say, you just can’t keep making this mistake, you have to do that. 35:40 And then they will try and internalize this, but the process of doing it is the thing that’s effect. 35:46 So let’s talk very briefly about diagnostic issues. 35:50 There are problems with diagnosis. 35:52 So one thing we know is that more boys than girls are diagnosed with ADHD. 35:59 What a lot of people don’t realize is that more boys than girls actually do have ADHD. So it’s not just that more are diagnosed. It is more common in both. 36:08 That being said is sometimes misdiagnosed because we go through that diagnostic criteria. Not everybody does. You will find certain other kinds of clinicians who may not pay as much attention to that, and then just may diagnose things. I’m like, well, the parent says they have this difficulty, so let’s do this. So what ends up often making the diagnosis? You think back to that. 36:30 That’s an ADHD iceberg. 36:33 If you have acting out behaviors, you’re a lot more likely to be diagnosed with ADHD. 36:37 If you’re more inattentive, you are less likely to be diagnosed. 36:42 And one thing that we see is that that acting out kind of behavior is less common in girls for a lot of different reasons. 36:49 There’s social reasons, pressures, things like that, But it also means that it’s going to be picked up less. Often in girls, It might even be overdiagnosed in boys, because there are other reasons that boys sometimes act out. 37:02 So, you may have people who are overdiagnosis, you may have people, depending on who you are like, if you’re female. 37:08 If you have a higher IQ, you may be under diagnosed. 37:14 Higher IQ thing is important, because if you’re smart enough, for lack of a better term, like if you have, if you have a greater fund, or the kind of skills you need to do in school, which is what IQ actually measures, not how smart you are, it’s like, do you know the kinds of things you need to know in school? Which is great thing people don’t always understand that, that’s really what we’re talking about. If you’re really strong and all those things, you can have other weaknesses and still do, OK? unless it’s really that. 37:40 So, what you’ll see is people who maybe don’t act out very much and have a lot of ability, they’ll do OK enough, even though they have all these deficits for a long time. 37:52 But, not forever. 37:53 The problem becomes, as you are expected to do more and more things on your own, in terms of organizing things, these deficits catch up with you. 38:03 The problem is, the older you get, the more likely you are to be questioned or doubted for having this. 38:10 So, sometimes we’ll have exactly this experience, somebody with a very high ability, say, top 2%, and IQ of 130 or above, And primarily in attendance, ADHD, but they always kinda got things well enough that they could get things done, they could use those other skills until they get to college. 38:30 Then they have to organize everything for themselves. 38:33 Then they have Trump. And there’s statistics about this, although they are weak, because the studies are not huge, But, in general, we know things along these lines. 38:43 In samples of kids who go, like, who are college bound, high school students, um, are eligible for college. About 77% of them in this country go on to college. 38:56 But the percentage for similarly macht, kids who have ADHD, it’s only 22%. 39:03 So something like a third of as many kids with ADHD actually go on to college. 39:09 Once they get to college, about 35% of that original group of kids who go to college, 35% of who are eligible to go to college, or on that track, 35% of them will actually finish ADHD kids. 39:26 It’s little less than half that, maybe 17%. 39:30 Some studies, say even low. 39:32 So, they get to a point where, once they’re on their own, they have a hard time getting into college. 39:39 Once they’re in college, they have a hard time, Twice as hard of the time staying out, because there isn’t somebody there to tell them what to do next. They have to organize everything themselves. 39:51 So all of these deficits, now, or the main problem, not the ability to do the work, is the ability to understand how much time it takes. 40:00 We, in our practice, one thing we see is, we’re often doing ADHD evaluations for people that are even higher than this. So maybe they have mild or abilities. But now they’re Ned School. 40:10 Or they’re in law school. That we’ve had exactly those things. And they have ADHD. 40:15 Now they’re at a point where executive function skills are absolutely critical to what they do. And they can’t do it. 40:22 Despite having great ability, and maybe even great grades. They can’t manage this on their own. And they get a lot of skepticism from their programs are like, well, how could you have gotten this far if you have this problem? 40:31 That’s what it looks like. If it’s mild enough to let you get that far, you can get yourself to a point where these things will get in the way. 40:37 So, the diagnosis issue is that it can be different, based on who you are, and how you present. 40:45 It’s always easiest, Problem is the most obvious, when it’s the most difficult. It’s same with any diagnosis. The more mild it gets, the harder it can be. 40:54 So, if you don’t make a lot of noise, if you don’t cause a lot of disruption, you may not be diagnosed. But you may still have trouble later, when falls on you, and if it’s not college, maybe it’s gonna be work when you’re expected to do these things on your. Obviously some kinds of jobs more than others. Now, I wanna give you play. 41:12 Favorite. Russell Barkley quote about five minutes left before we’ll do questions. 41:17 And I will show you something that to me is a very, very important analogy. 41:24 Oh, and we got to get to the coaching stuff yet. 41:26 So, my favorite Russell Barkley quote, his ADHD researcher who’s written quite a bit about this. 41:32 He would say ADHD then, is a disorder of performance, more than a disorder of skill, A disability and the when and where. Unless, in the how and what the behavior? 41:42 Those with ADHD often know what they should do or what they should have done before, but knowing provides little consolation to them, little influence over their behavior and often much irritation to others. Such knowledge seems to matter little when they actually are behaving at a particular pole. 41:59 They know the rules. 42:01 They know how they should have done it, but they can’t do, but that’s always what they’re asked. And that brings me to my favorite analogy, the color blindness, analogy. 42:12 And I apologize if anybody has this particular kind of color blindness is most common kind of red, green kind. 42:17 So if you have normal vision, you’re going to see three different color apples. If you have red green colorblind, they’re all going to look some various shade of yellow. 42:28 So, as you can imagine, you know, this as an analog, for ADHD, when people are saying look, you just have to pick up the red app, you have to quit picking up the green ones. 42:37 You have to quit picking up the yellow ones, You have to pick up the red, and they’re like, OK, but they can’t see it. 42:44 But we keep telling them to do it, And it doesn’t matter how many times you tell somebody to do it, if the process that allows them to do this is not work. 42:54 So, when we try and explain this over and over again, what do you understand what you did wrong? You know, you need to do here. It’s like, Yes, they do, but that doesn’t help them change what they’re doing. 43:04 So, what do you do instead? 43:07 We don’t try to six executive functions the same way we don’t. At least, you know, I don’t think it’s worthwhile to try and fix. Suddenly you don’t fix colorblindness, you support them. You come up with a workaround. You come up with modifications. 43:20 You quit talking. 43:21 You don’t think it’s worth explaining what they’re supposed to do, but don’t assume that that’s going to fix it. Tell them there are three different colors of apples. But, let’s find a different way to do this, You know, it helps that they know what they’re going to need somebody else to do. 43:36 You should, in my opinion, and I’m not a physician, or you should consider, if the problem is significant enough, medication as an option. 43:46 It has a pretty good track record, although like any other medication, there are problems and downsides. 43:51 But, there aren’t too many other kinds of medications you can take for any other sort of psychological psychiatric condition that you can only, you know, you can, you can take during the days when you need it. And not the days when you don’t stop if it is working with you. 44:06 Without much of a, you know, it’s worth trying If it’s going to help somebody do these things on their own, boost these, these abilities to control their behavior and their attention consider school supports. Schools are getting better about this. 44:20 You know, all of these kind of supports are gonna follow the same thing where I call it, building habits, not processes with the idea that, we’re going to take these executive functions that are not working so well and we’re going to try and externalize them some way. 44:33 Instead of doing like what we’ll often here, working with, with schools, where they’ll say, Well, they just need to be responsible. 44:39 Like, that’s a great idea, but that’s not, right. It doesn’t matter how responsible they are, or whether they should be able to do this by this age, just saying that in pre-supposing, that won’t help this kid. 44:51 So if you want to learn the information, don’t expect them to get everything down in notes. 44:56 How ’bout you expect them to attend this, Give them a copy of the nodes. You want them to know this stuff. But you want them to write notes. I will do the notes. So, if we can give them do the old assignment boxing where, say, like child has to write the assignment in a book. 45:12 Then before they leave the classroom, the teacher checks to make sure that it’s correct insides. 45:18 So that we know the information can get whole lot of, this is done electronically now, through school websites and things. 45:25 But, like, if the if the task can get home and somebody can help them with, to say, oh, here’s the, you know, oh, we need to do this, But if they don’t, if they didn’t remember it. 45:35 If you don’t get it home, and they do wrong, sign it, Nobody can help me with that. Don’t even help them if they forgot. 45:40 They need to know what it is. You can probably see a couple problems with this. It relies on other people being focused. The teacher must remember, every single time to sign the book, the teacher must update the page on the web page every day with the assignments. And a lot of times, we see these things not happen. 45:56 This is the difficulty with this, It will, it requires other people to be on talk, but it’s still something to push. 46:03 School supports. Some schools have things like where they have, like a modified study hall. Where kids with IEPs with plans work for educational support can have a period of day. or a few times a week. Where somebody goes through the backpack and make sure that things are organized. Make sure they have all their assignments, They have miss things. I can’t tell you how helpful that is. 46:27 That’s that is one of the most helpful things that can be done. And, remember, they’re not doing the work for them. They’re just making sure that they know they’re making sure what they have to do, so that someone else can do some of those executive functions for them, And then the kid can actually perform the task, which is what we’re going for. 46:44 We talk about things like, uh, environmental modification. 46:50 Like, if you wanted to my, my analogy here, are the apples, know, how about getting rid of two colors, the apples, stuff they can get differentiate? Can we get rid of some of the things that are causing them problems? 47:02 And the last thing is coaching. 47:06 Now, I know this was not planned on my part but there’s presentation through this same organization tomorrow. That’s going from this organization, Chad, where they’re going to talk about coaching. And a brief thing about this is, coaching is not the sames therapy. 47:22 Coaching is focusing people on the things they need to do to try and teach them happens. Like I mentioned in the last slide, habits, rather than a processing, like, Oh, you need to do this paper this way to do this. It’s always like, you need to we need to figure out how long it takes to do something first. This is what we do first. We need to make sure we have our materials. 47:43 We need to make sure we started working at this time every day, You know? 47:46 And then someone will check on an ADHD coach, tells them what they need to do, and then follows up with it. 47:54 And this is something that psychologists, like I did when I was working in schools where we do things like a kid needed to do something with CLAS. Haven’t come see me first. 48:05 And say, OK, we’ll go into this room, this is what you’re going to need to do. 48:10 You’re going to do this, this, and this, OK. 48:12 Let’s repeat those, this, this, when you’re finished, I want you to come back and tell me how it went. 48:18 So you’re focusing their attention on the things they need to do. 48:22 And then, you know, so hopefully, they’re thinking about it, which keeps it higher up in their attention, and then it’s going to be reviewed. 48:29 So, that whole idea of mental plan, you’re not relying on them to make the plan on their, on their own. 48:35 You’re making them focus on the plate. They still do the plant. 48:38 They still review it, but they’re using you as a support. 48:41 So these are the kinds of things that you want to end up doing. 48:45 ADHD, coach, it’s really more for adults and for, to some extent, for adolescence. 48:51 But the, the principles of that are important, the idea of taking these ideas. 48:56 And, you know, instead of saying, Oh, you need to be Oregon, Here’s what you need to do next, and then having them do, here’s what happens after this. 49:07 This is where the coaching comes in. 49:09 Therapy for ADHD is really not very effective. 49:13 You can give people therapy for the problems that happen around ADHD. Some difficulties, they have to skip talk somebody out of ADHD. You can’t explain things enough like this, we’ll change this. Is not to say this is providing a series of actions that are concrete. 49:28 And the idea of building habits to hopefully, say, like, here’s a way to approach every task, once they get used to it, hopefully this is something they bring, or they can be more independent on there. 49:40 So I wanted to make sure that we still have time for questions with about 10 minutes left, and I would love to open the floor to questions. 49:48 I can’t see them at the same time, so they will be read to me. 49:52 Do we have any questions by any chance? 49:54 Yes, we down. OK, so first and foremost, thank you so much, doctor Diver, and that was phenomenal. 50:00 And so I’m going to start on the questions. 50:03 So our first question is how can we know what? 50:10 Let me try that again. How can we know what is age appropriate for a particular age? And then the second part of that is, are there gender expectations? 50:20 Yes, there are, there are both. And I’m gonna give you an example. 50:23 This is why psychologists use the tests that we did. 50:28 So, one of the things you can do is, you know, if you have any questions about something, that seems like, Well, I’m not sure if this is appropriate or not. 50:36 You can always ask someone to see. You know, at least, like, start off with that. Say, why is this OK at this age? Should this be happening? We do see inappropriate things sometimes. And I hate to say it. 50:47 I’ve been in schools where this is coming to the curriculum, where they expect kids at a certain age to sit down for very long periods of time because they think that reflects that it’s a good educational program. 50:57 It’s like, Well, kindergarten kids may not do that, and you can set an expectation. That is an age inappropriate. 51:04 So the thing is: you have to measure your own expectations. If you decide to go for an evaluation someplace through the school, or through a practice or anything like that, we have instruments that are designed for this. So when we’re going we’re asking specific questions, they are measured against other kids. 51:22 So the most common one that you’re probably going to come across, which is my favorite probably psychological test of all time, is the Basque three the Behavior Assessment System for children. 51:32 And it’s based on a sample of something like 10000 kids of all different ages, all different clinical issues and things like that. 51:41 So the idea is, when you look at responses on that, the child made, its parents made in different versions of it, You’re comparing them to everybody else, and it will give you a sense of, OK. Now, this is what’s reported for six year old. 51:54 How is that, compared to other six year olds, we can actually look at that and say, Now, this, this is how six year olds are, are, like, No. 52:02 This is actually, this is more impulsive than 95% year, so that gives you some. 52:09 Um, Basque also has things about executive function. So, that’s the thing I want to take away There. 52:16 Is to realize that if you’re not sure, there are measures that can be done in a variety of settings, that will help you describe your behaviors and then have that imperative formal way to what’s expected from other kids. 52:29 I hope that answers the question. 52:31 No, I think that does, thank you. 52:34 OK, so our next question is, Do all of the symptoms have to be present in both environments? 52:42 Um, I think most people interpret it that way, but the thing is, the symptoms, the thing we really look for is, the symptoms are there. 52:51 At least all of the symptoms can be put together from all the set, all the settings put together. But the impact is more than one set. 53:00 So, you don’t have to show all the things, but if you have, say, seven symptoms in one place, and they can always say four and another, but both are impacted, that’s good enough. You’re looking for the end. 53:10 We’re both who would say, Yeah, this is a problem, OK, that makes sense. That makes a lot of sense. 53:16 So next question I have is we always hear I’m going to let ADH take eds use things like fidget spinners, sensory items, et cetera, when doing schoolwork. Is this a good idea or is this multitasking? 53:32 I’m gonna tell you that you hear a lot of stuff like using those things, but there’s virtually no research behind it. 53:38 So I would say no, it’s not a good idea. I mean, the thing is, this is not helping people pay attention, that is clear. 53:46 There might be a benefit of saying like, well, they’re not doing something that’s more distracting, That is possible, But you have to realize what the tradeoff is. Like a kid doing a fidget spinner is not paying attention to the work, but maybe they’re not getting up and disrupting the class But that’s the thing. 54:02 Like, this was a big issue for a lot of psychologists were like, Oh, version of fidget spinners. Like, where do you get back to? It’s like, it doesn’t come from our work, because it doesn’t support the research isn’t there to support. 54:15 OK, now that’s very good to know, because most people don’t know that, I didn’t know that. 54:20 So our next question is: At what age do parents start to pull back from coaching, so teens’ become more independent, for example, like in college? 54:31 It’s this isn’t an easy answer, but I’ll put it this way. 54:39 When I started off in this field, there were a whole lot of people who thought that you outgrew ADHD and the evidence is pretty strong that you don’t. 54:48 Um, but if people can become less impulse, les fidgety, mostly, but they still have these difficulties, so I would say, when you do things, you stop coaching efforts when they don’t need it. 55:03 And if they need it, you continue it through your whole life if you have to. 55:08 If you need help staying organized, you need to figure out what that is. 55:11 The other thing you just have to realize, is that, if you’re in public school, there’s a lot of things can be provided for you. 55:17 If you’re in college, or you’re in the workforce, those things are not necessarily provide. You may have to take some steps to make that happen. You may have to have assistance. 55:28 But, you know, there’s a reason that that we tell people that rely on the alarms on their phones and things like that. Except set an alarm at 3 30 every day. You’re going to start reading, you’re going to start like, no matter what, the course phones present their own distraction. So, you have to manage it. And I just want to go back to say one thing about fidget spinners. And things like that. 55:49 You’re going to find this stuff, sometimes, in occupational therapy, and it does have a use there, but I’ll tell you, they don’t have research to support a lot of what they do with this, either, at least not the research done by the standards that we would. 56:03 Uh, but it does show that a lot of times, it stops more disruptive behavior. 56:08 Especially if you see like, the, like, the seats you have to balance on, it stops it, or it can stop more disruptive behavior, because you’re focusing on that instead of on something else. 56:18 But we should mistake that, four, this will help you concentrate on their work. There’s not really evidence for them. 56:26 OK, gosh, I know and that’s so important to know. Thank you. 56:29 And so, another question that we have is, they said, curious about your reaction to recent news stories of high rate, diagnosing ADHD and prescribing Adderall for young adults. That is being said to be occurring with online tele therapy groups. 56:48 Like, sorry. Sorry, Paul. 56:52 I’m not familiar with. whoops, There’s a lot of them. 56:54 Um, well, I’ll try and answer that, but you’re going to hear my own personal bonds freely said that this bias based on the way that I was trained in the things that we do. 57:05 Um, I think there’s, There’s a, there’s a couple of things to think about. 57:14 They used to do a lot of psychiatrists. Psychiatry, we were talking decades ago. 57:20 They used to do what They would informally call diagnosis by prescription, where they would say, like, well, I don’t know if kid has ADHD, or ADD, at that point. 57:32 say, but we’ll give them Ritalin. The first one, you can get stimulant and said, well give them Ritalin, and this, they do better than they accept. 57:42 It doesn’t take long to figure out that everybody does better where they understood his it will have everybody perform them. It will know that’s why do people drink coffee and tea? Everyone people do better with students. 57:55 It’s it’s it’s a different effect. 57:58 But one of the reasons that people are getting stimulates These people know that it has a positive effect are working to increase their grades. Not a great idea, because if you don’t have this particular deficit more at risk for having problems for doing this, and we think about it, also, it is an abuse of medication. If you’re going to do that, but it’s common on college campuses where people will sell to, people that want to do better on the test, whether it works or not, they think that it will. 58:25 So we have that going on when we talk about these other, you know, so we have a lot of people that are seeking loans when we talk about how ADHD is dying. 58:33 The way we do it, we’re going to use, we’re going to try and establish that all these criteria are met. We’re going to try and measure it some way. It’s difficult, because most of these measures are not direct or indirect. Like, you’re asking people. What we’re trying to, we’re trying to do that. And we do have some direct measures. That’s a longer discussion. 58:51 Like, whether they’re useful or not. An issue. 58:57 But in other settings, like primary care, they may use a single, uh, a single questionnaire like the Vanderbilt or something like that, which will say, like, do they have this problem? Do they have this problem? 59:09 And parents or the person themselves can say, yes, yes, yes, yes. 59:14 These questions all have what’s called face validity. 59:18 Face validity just means, like an item means when you think, that’s measuring what you think, so a bad part about that, is it OK, if you know what you want it to say. You know how to answer your question. 59:28 So if it says, Do you have trouble with attention, I’ve terrible trouble with attention, you have trouble with impulsive. If you know what you’re asking, you know how to answer, to get the results you want. That’s the downside. 59:40 So, you wonder, sometimes, with some of these people who don’t know how to use clinical instruments, or don’t have the time to do it, they’re going to use something, it’s easier to manipulate. 59:49 So I’m concerned about that not because it’s telehealth, but sometimes because of the, the, the training, and the quality level of the person at the other end, are they doing an assessment, or are they asking you questions? Do you know how to answer to get what you want? 1:00:03 It is interesting. one thing you may have seen is that everybody’s having trouble getting their ADHD meds right now, because there have been so many more diagnoses over the last year or so. 1:00:13 Manufacturers anticipated the need for the year, and they’ve run out because they’ve had more, they’ve had more prescriptions than they expected. 1:00:24 So, something is driving this, and I think where it’s gonna be a little while before we find out exactly why, but we do know that there’s a lot of people who are looking for this kind of medication right now from a variety of sources. 1:00:35 So, that’s a long answer, but it’s a difficult question? 1:00:38 No. That’s completely understandable. I do have two more questions. 1:00:42 Is that all right if we We talk about them? 1:00:46 Absolutely. 1:00:47 Yes. I’m sequestered in my room with. Just wanted to double check and I know some of the attendees might need to hop off. 1:00:57 First and foremost, I just wanted to say thank you so much for attending. 1:01:01 Tomorrow night, on December eighth at seven o’clock PM Eastern Standard Time, we will be continuing this conversation on ADHD at our Tourette Talk with Chads Founding Director and ADHD ADHD coach herself, Jan Melrod. 1:01:19 To register, please go to WWW dot NJ CTS dot org slash tourette Top. 1:01:27 With that being said, the blog will be open around tomorrow available for the next seven days. Any questions that you may have or that we might not have been able to get to. Feel free to post it on there. And it will be active for the next seven days. And you can go to WWW dot … 1:01:46 dot org too see, to be able to ask any questions as well as get an archived recording of tonight’s webinar. 1:01:55 So, now that we got that out of the way, next question is, I believe what this person means is, with telehealth or any type of therapy or coaching for ADHD, it says that, my problem, or the problem, is that it’s not covered by insurance. 1:02:20 Um, I don’t know what they were looking into, but they said three K is very expensive, what can we do? 1:02:26 3000. 1:02:27 Yeah, four? 1:02:31 I don’t even know. It didn’t, They didn’t specify. I thought that sounded kind of high. 1:02:39 We’ve seen a range. 1:02:42 A full psychological evaluation is expensive. 1:02:46 3000 is toward the high end of that. 1:02:48 We’ve seen some practices that charge 4000, um, for a full neuro psych evaluation, which I just, I can’t agree with it. I don’t think that’s necessary. 1:02:59 For an evaluation, it can be expensive, because most of the time, you’re talking about what you’re talking about kids, and you aren’t you have to look at the learning issues, always, when you’re doing something like this. 1:03:09 Because ADHD and learning disabilities are, which is the, the school term, or learning disorders, which is the clinical term. 1:03:16 They’re not exactly the same, but that’s another discussion. 1:03:19 These things up commonly co occur. 1:03:22 So you have to do, if you’re gonna do this evaluation, you have to do a lot of stuff, and it takes a lot. I don’t think you need to do a full neuro psych evaluation to answer this question when you’re, if you’re an adult. 1:03:36 They frequently don’t ask all these questions. No, you’re not normally concerned about learning disabilities or things like that. 1:03:41 If you’re over 18 and you’re out of school, it’s a much shorter process. It doesn’t have to be this huge evaluation. It should reflect that in the in the cost. 1:03:51 Um, a lot of these kinds of evaluations, though, for what it’s worth. 1:03:56 These can be done over telehealth, because they’re just asking questions or even having a person fill out a form. They don’t have to be in the office for them. 1:04:04 And I know that a lot of coaching is delivered to Telehealth and same way other things are done But I know insurance companies are funny that some cover it standards at some do not. It. sometimes it has to do with the level practitioner. 1:04:20 At our practice, we do telehealth. Most people seem to want Telehealth and we have mics now in person and telehealth. 1:04:26 And they, they’re covered, but we’re all licensed. 1:04:30 So I’m not sure. 1:04:33 But it’s an issue, telehealth is, is taking an unusual role right now. 1:04:39 And some providers will say they want to use their own people, Or they’ll use, you know, they have some other restrictions like that. But paying out of pocket $3000 is a lot. 1:04:50 I’m just gonna, I don’t know the situation of the person here, but if it’s a kid, remember that if a child is having particular difficulties that are affecting them in school, they should be eligible for an evaluation through the school district for free. 1:05:05 Now, that’s an evaluation for special education services, And but they have to the point, you need those kinds of supports. 1:05:13 The school should evaluate to determine whether that’s necessary. And that’s a bill cost, including if they have to send you to a psychiatrist for like the way that works in New Jersey. 1:05:25 ADHD has to be determined by a physician, that is not for now for us, but are usually take our stuff. But they have to refer out. They can’t do it themselves, but they should pay for them. 1:05:36 So if it’s somebody in the public school system that are having significant difficulty at school, I would explore that option first. 1:05:43 It’s not the same as a clinical evaluation, but free, and you’re entitled to it. 1:05:49 Especially if you think they need support in school beyond the regular subsidy, if it’s an adult. 1:05:54 You may have to learn how to talk to your insurance company and see if they’ll cover it. But just paying out of pocket at $3000 for an evaluation is a lot. 1:06:02 And I would have to know, the things were really, really bad before I would pay $2000, Just to find out the answer to request. 1:06:10 I hope that makes sense. 1:06:12 There’s money. It’s like, $3000 is a lot. 1:06:15 Now, it’s definitely, definitely, as, and that the person read through and said, she meant the evaluation of ADHD by clinical psychologist. 1:06:24 It could cost that much work. It shouldn’t cost that much for it, That’s why I don’t believe it’s like that’s not how I would do it. If it’s an adult. 1:06:32 I’m not doing the cognitive stuff, I’m not doing these other things, I’m doing maybe a third of them, and it still, unfortunately, work. It probably wouldn’t work out to over one thousand bucks. 1:06:41 But if I knew you had to pay for it out of Pocket, I’d probably try and help you figure out some other way to do it. Just say like, well, if you want to want to go to a psychiatrist, and do their evaluation, it may actually be shorter. They may not to test. It will still be probably close to one thousand ohms. 1:06:56 But it’s hard to imagine they wouldn’t pay. 1:06:59 Anything Seward’s insurance company will come. What would they want you to do? 1:07:03 See what they would cover? 1:07:06 That’s a very good question. No I definitely I definitely agree with that. 1:07:11 So, we have two more. 1:07:15 one of them is when someone was diagnose app, when someone was. 1:07:23 When someone has a diagnosis of Tourette syndrome and OCD, not ADHD, but as clary, but is clearly displaying symptoms, matching what you describe. 1:07:32 Could it not be ADHD, but it was caused by either Tourette’s syndrome and OCD? 1:07:41 That’s that’s almost right. Yeah, that’s very astute, but the thing is with this with Tourette’s. And that’s the other. Like the two disorders that we spend our time explaining over overdose or ADHD and Tourette’s, because Tourette’s is also poorly misunderstood, poorly understood. 1:07:57 Your organization helps tremendously with this, But most people it’s the same. 1:08:03 But now this is the way I look at for most people, unless ticks are very severe. It takes, you know, the main problem. It’s the other stuff that goes along with. 1:08:14 And for many people, like when we see someone coming in with Tourette’s, we’re expecting another diagnosis also, because that’s usually usually have another one. 1:08:24 And the ones you’re going to see the most commonly heard, you can have a lot of things that co co occur, but we look for three. 1:08:33 So, with Tourette, a very high percentage also have OCD and also have ADHD. 1:08:40 It’s not the Detroit causes it. 1:08:42 It is part of the same constellation of issues. 1:08:45 The third one is, like rage incidents. 1:08:49 So acting out behaviors that don’t fit a clear diagnostic profile, that’s a tough one to say, because it doesn’t fit. 1:08:56 But most of the time, we kind of expect people with Tourette’s. We’re always looking to see if they also have OCD and ADHD. 1:09:04 So if the person is demonstrating ADHD, you might want to consider two things. First of all, was the other diagnoses simply not corrected? They just don’t realize the person also has ADHD. 1:09:18 Um, because, more often than not, they are going to give we expect. 1:09:23 Or, if you are already getting treatment, if you don’t have the full diagnosis, but, you see things, you can still treat the symptoms. 1:09:32 So, it’s something that you can try, or something you can explore say, like, they may not have everything. But we know there’s at least these features commonly co occur. So, can we treat, Can we try and treat that, and see if it helps? 1:09:43 We come into, It’s more common to come into issues with, They don’t meet the full criteria for OCD. 1:09:50 But they have a kind of … 1:09:52 OCD profile that absolutely needs to be treated even if they may not meet the full criteria. They usually do, but sometimes they don’t. 1:09:59 So for this, the one thing I wanna get across to you is that you’re probably right, is that this is an issue that they treat, Whether they want to call it ADHD or not, isn’t as important as whether they’re actually going to address the issues, that the things that you see. 1:10:16 I hope that makes sense. 1:10:18 No, it does. And then our last question, and after this, we’ll wrap it up. 1:10:22 Um, last question is, I’m thinking, my son has ADHD. 1:10:27 He’s a junior in high school, I’m worried about his procrastination, and how he always starts off the here with A’s, But then, it starts dropping off, especially when he is getting bored. 1:10:38 I’m worried, when he goes to college, or when he starts college, I understand. 1:10:46 So, if you’re interested in getting a diagnosis, the thing that they’re going to ask about, of course, is, Did he show symptoms of this before age 12? 1:10:54 What I didn’t mention before is, sometimes they’ll call it subclinical. 1:10:59 The idea that you could have problems with this, but not so severe that they call it a disorder. 1:11:04 So, the question will be that, it’s like, is this just a weakness for him, but not enough to be considered a disorder, or is this a disorder that was missed? 1:11:12 So you’re looking for the impact to be clear before age 12, As opposed to, like, well, this isn’t something he’s great at. 1:11:20 And now that he’s being asked to do this all the time, this is, this is somebody’s going to have trouble, you can still use some of the same techniques, or you’re probably not gonna get medication or somebody diagnosis. You can use some of the same techniques. 1:11:34 The thing to remember those people who do have executive dysfunction. They don’t like these Stephanie’s she don’t necessarily like to be focused, because they don’t see. 1:11:44 They don’t see that there’s an issue. 1:11:47 There are a lot of people who just have problems with organization. They have problems with procrastination. 1:11:51 They don’t have a disorder, it’s just a general, same thing with reading issues or anything else. Like you’re gonna have trouble with this, but it’s once you hit that threshold, it has to be significant impact. It has to be significant symptoms. 1:12:03 Before, we did say, now, this is not just a regular variation, that not everybody’s graded everything. 1:12:08 Now, this is a disorder, This is stopping to do what they need to do, that’s going to be, that’s going to be the deciding factor. There. Is it enough to give them a diagnosis. 1:12:18 And if it isn’t, what can you do? These coaching techniques will help anybody that has problem in these areas. 1:12:24 As long as he buys it, I will give you one suggestion. 1:12:30 People to edit. This is this. wouldn’t require more time, definitely, to figure out what to do. 1:12:35 But if, if there’s things that he’s motivated by, because if you have to realize, like especially when you’re, you have the adolescent brain isn’t finished with its higher order thinking skills like, you finish that development, probably around age 25 so long after all, this is, oh, I’m sure, hope you’ve gone through all this stuff. 1:12:55 That these things may not be very important to him but you give them something to motivate, especially if it’s a subclinical, kind of figured out a disorder. It’s, like, if you do this, you can earn this, or, you can have that. It’s not the only taking something away giving something. 1:13:10 It’s like, do you think this, here’s something you can earn. 1:13:13 Something like that can keep motivation go, sometimes people will say that’s briberies, I know that’s, that’s reinforced. It’s like, you don’t go to work and they don’t pay. 1:13:22 It’s like, if you’re, If you’re gonna get something finished, that’s extra like, I need you to put extra time into this extra effort, no reward you for, It’s something to consider while you’re looking at the other things like that. 1:13:35 Give them something extra, if you can. Something that, that is important to him, if he can meet the goals that you think he should have. 1:13:44 Awesome! Well, thank you. So, so so much, doctor, dive bar. None. Also, we’re gonna, we’re gonna wrap it up. 1:13:52 So once again, tomorrow night, December eighth at seven o’clock PM. 1:13:56 Eastern Standard Time, we will be continuing this conversation on ADHD at our Tourette Talk with Chad’s Founding Director and ADHD coach herself, Jane Melrod. 1:14:09 To register, please go to WWW dot N J CTS dot org slash … talk. 1:14:17 Thank you so much for joining our webinar on What Does it mean to have ADHD? 1:14:22 There is an exit survey. 1:14:24 Please take it. 1:14:26 Please take a moment to complete it. 1:14:28 The webinar blog will be open shortly and available for the next seven days on the Endzone CTAS website for any additional questions that were not covered tonight, as well as any questions that you might have within the next couple of dates. 1:14:44 Now, that website to act to Access it is WWW dot N J CTS dot org. Also, an archived recording of tonight’s webinar will be posted to our website. 1:14:57 Our next presentation will be on sensory processing disorder when Everything is too much presented by doctor Felicia Castagna on Wednesday, January 18, at 7 30 PM Eastern Standard Time. 1:15:12 With that, I hope you all have a wonderful evening. And thank you so much for attending.


  1. Brenda says:

    Are you saying that kids with ADHD will develop Tourette’s?

    • Eric Deibler says:

      Thank you for asking me to clarify this! I certainly did not mean to imply that kids with ADHD will develop Tourette Syndrome. Rather, in regard to TS, kids with TS more often than not have another mental health diagnosis that co-occurs with it. Of these conditions that co-occur with TS, ADHD, OCD, and a range of conduct or behavior problems are the most common. Although estimates vary, it is fairly safe to say that over half of all kids with TS also have ADHD. ADHD does not develop into TS – they are separate disorders. Hope this helps!

  2. Narciza says:

    You answered this question in regards to ADHD, what about for anxiety? — How can we know what is age appropriate for a particular age? Are there gender expectations?

    • Eric Deibler says:

      After the Q+A session on Wednesday, I realized that I had not addressed the anxiety portion of your question – my apologies! I’d like to answer this question in two ways – one clinical, and one more personal.

      First, on a clinical level, I will again reference the Behavior Assessment System for Children (BASC-3), although there are many other testing instruments that are available and may also be able to address this clinical concern. The BASC-3 was “normed” on a sample of thousands of children from preschool age all the way through college age, which also included children with a variety of clinical, developmental, and behavioral conditions. This very large sample size allows a clinician to compare a child’s ratings on a variety of important clinical aspects, including anxiety, to the ratings of thousands of other children to look for behaviors or symptoms that are markedly different form other children their age.

      Furthermore, the BASC-3 has a sample size that is so large that it allows comparisons on multiple different sets of norms beyond simply age, such as gender, ADHD, Clinical diagnoses, and more. In short, and by means of an example, if you are evaluating an 8-year-old girl with ADHD and possible anxiety, you can compare her anxiety ratings not only to all other 8-year-olds together, but also to other 8-year-old girls specifically, other 8-year-olds with ADHD, or even other 8-year old girls with ADHD. This also side-steps the very real issue of gender expectations – is a child’s emotional experience or behavior markedly different from the group of with they are a part, regardless of reason?

      Second, on a more personal level, I use the same phrase both when I work with parents and when I train our Post-Doctoral Fellows: “If it seems strange, it probably is”. By this inelegant phrase, I mean that if you notice something unusual, you should pay attention to it. If your child seems distressed, pay attention to it. If your child does or feels something that seems like it could be concerning, pay attention to it. Don’t be afraid to ask questions to investigate your concerns. If your concerns are unfounded, then you can adjust your expectations accordingly; if your concerns ARE founded, then you are addressing a real need that your child has. Both of these outcomes are positive!