ef in young people with adhd and/or asperger’s...4 major problems in post-secondary transition for...
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EFinYoungPeoplewithADHDand/orAsperger’s
duringtheirPost-SecondaryTransition
ThomasE.Brown,Ph.D.
Director,BrownClinicforAttention&RelatedDisorders,Hamden,CTClinicalAssociateProfessorofPsychiatry&BehavioralSciences
KeckSchoolofMedicineUniversityofSouthernCalifornia
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A New Understanding of ADHD
ADHD = developmental impairment of the brain’s management system, its executive functions.
(Brown, 2005, 2006, 2013)
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What are “Executive Functions” (EF)?
¨A wide range of central control processes of the brain that interact dynamically to:
¨connect, prioritize, and integrate cognitive functions–moment by moment
¨ like conductor of a symphony orchestra
¨Lezak: “Will you do it and, if so, how and when?
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Characteristics of ADHD Symptoms
¨ Dimensional, not “all-or-nothing”• Everyone sometimes has some impairments in these functions; in ADHD: chronic, severe impairment
¨ Situational variability: “If I’m interested”• Most persons with ADHD have a few activities where ADHD impairmentsare absent
ADHD looks like willpower problem, but it isn’t!
T.E. Brown, Attention Deficit Disorder: The Unfocused Mind in Children & Adults (2005)
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Executive Functions OftenImpaired in ADHD
Executive Functions
Organizing, prioritizing,
and activating to
work
1.Activation
Focusing, sustaining focus, and
shifting focus to tasks
2.Focus
Regulating alertness, sustaining effort, and processing
speed
3.Effort
Managing frustration
and modulating emotions
4.Emotion
Utilizing working
memory and accessing
recall
5.Memory
Monitoring and self-regulating
action
6.Action
T.Brown, Attention Deficit Disorder: The Unfocused Mind in Children & Adults (2005)
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Executive Functionsoperate in dynamic, integrated ways
For example, EF of “focus”•Does not mean
• as in holding the camera still to take a photo of an unmoving object
•Does mean• as in focusing on the task of driving a
car
Brown TE. 2005.
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Scaffoldingmay support or undermine executive functioning
¨Parents¨Siblings¨Teachers¨Friends (peers and adults)¨Extended family¨Physician, counselor or therapist
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Post-Secondary Transition
Finishing high school and then:¨Moving away from home to go to college¨Living at home while attending college or trade
school¨Living at home while seeking and/or sustaining
employment¨Taking a “gap year” to travel or defer decisions
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Impacts of Post-Secondary Transition
¨ends predictable sequence of school years¨multiple decisions impacting family dynamics,
loyalties, and finances¨Loss/distancing from usual scaffolding relations¨need to integrate self into new social systems for
work, schooling, living arrangements ¨much uncertainty about one’s ability to meet new
challenges, how one will fit in or not, future
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4 major problems in post-secondary transitionfor young people with ADHD/Asperger’s
¨Uncertainty about realistic aims/choices for now and future (schooling, location, career)
¨Persisting EF impairments not adequately treated (wish to avoid meds, med access problems)
¨Avoidance of help-seeking (wish to feel and appear as adult who does not need support)
¨Social anxiety exacerbated by loss of supports and unfamiliar demands of new situations
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•SocialAnxiety(socialphobia)Adolescents(13-18yrs) 11.7% (Burstein,etal.,2011)Adultsw/ADHD(18-44yrs) 29.3% * (Kessler,etal.,2006)
*(mostfrequentlyreporteddxcomorbidwithADHD)
Peoplewithsocialanxietyusuallyexperiencesignificantdistress inanticipatingorbeinginsituationssuchas:• Beingintroducedtootherpeople,beingteasedorcriticized,• beingwatchedorobservedwhiledoingsomething• meetingpeopleinauthority("importantpeople/authorityfigures")• Feelinginsecureandoutofplaceinsocialsituations("Idon’tknowwhattosay.")• Embarrassingeasily(e.g.,blushing,shaking),meetingotherpeoples’eyes• Swallowing,writing,talking,makingphonecallsifinpublic
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James– 23yo collegestudent
• Graduatedhighschoolwith3.6GPA• Enteredacompetitiveuniversityasengineeringstudent.Didwellinmathcourses,butstruggledwithwritingessaytestsandpapers
• Avoidedattendingclasswhenpapersweretobehandedin,thenfeltunabletoresumeclassattendanceorcontactprofessororTAorlearningcenterbyemail,phoneorofficehoursvisit
• Wasputonacademicprobation• Tookvoluntaryleaveofabsenceandfoundajob• Soughttreatment1-1/2yrs afterleavingcollege—wantedtoreturn
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James(2)
• Initialconsult:handsome,well-built,articulate,abitshy,wantedtoreturntouniversitybutfeltneedtodealwithhisproblemswithwriting,difficultieswithreadingcomprehensionandrecall,andshynessabouttalkingwithfacultyorTAs. FatherdescribedJamesassomewhatshyinchildhoodandadolescence,butnoproblemswithschoolattendanceorgettingworkdone.Someparticipationinyouthsportsleagues,but“notsupersocial”,“tendstopullintohisshell”.
• Currentlylivingwithgirlfriendwhodominatedanddependedonhiminapartmentpaidforbyparents3hoursfromawayfromparentsinthecitywherehehadbeenattendinguniversity.Hadjustendedjobduetocompanymoving.Noabuseofdrugsoralcohol.
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ImpressionsandRecommendations
DX:ADHDwithSocialAnxietyDisorder• Educatedpatientandfatherre:diagnosesandnatureofphobia• Recommendedcognitivebehavioraltherapyincitywherehewascurrentlylivingwithgirlfriend.Initialtarget—getanotherjob.Longertermgoal—increaseabilitytodealwithfacultyandstaffre:school
• RecommendedLDXwithstartofFLUafterLDXdosestabilized• ReferredfortreatmentofADHDandtutoringtodealwithwritingproblem
• Supportedhiswishtoreturntoschool,butsuggestedstartingfirstwithjustonecourseinlocalcommunitycollege.
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Arthur19yo collegestudent
• Camewithbothparentsafterbeingterminatedendof1st yearfirstyearofstudyinhonorsengineeringprogramatcompetitivestateuniversityduetolowgrades
• Hadbeenhonorstudentinhighschool,participatedinroboticsclubandcontinuedactivityinBoyScouts.Limitedsocialcontactsoutsideofschool.
• Hadbeenseenbymeinitiallywhen8yo—diagnosedasADHDwithAspergers.StartedonATX(helpfulat80mgqam).Seemedtobedoingwelluntil8th gradewhenaddedLDX40+Dex 10boostertosupportEFandhomework.Respondedwell,parentssupportive,nofurthercontactuntilendof1st yr college.(noprepfortransition)
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Initialpresentation
• Tall,thin,tense-looking,limitedeyecontactexceptwhenaddressed,dressedinbaggyjeans,hairpulledbackinponytail,spokerapidly.
• “FoundcollegewasreallydifferentfromhighschoolwhereIwasusedtotheplaceandthepeople.Itwasreallyhardtogetusedto.”
• “Didn’ttellmyparentsIwashavingtroubleuntilendofyearwhenIknewIwouldnotbeabletoreturn.Wastooembarrassedtotell.”
• “I’mextremelynervoustalkingwithotherpeople”• “Wenttoclasses,butmostlykeptinmyroom,hadnofriends”• “Lotstroublewritingpapers,buttooafraidtogotowritingclinic”
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ImpressionandRecommendations
• Socialanxiety,ADHD,dysthymia,Asperger’sDisorder• ContinueATX80mg,LDX40mg,Dex 10mg,AddFLU10->20• PsychotherapywithCognitiveBehavioralfocusx1q2weeks• Encouragedparentstopushhimtodomoresocialinteractions,e.g.gotostores,makephonecalls,settingupstudygroups,drivingself
• Continuetoliveathomewhilestartingsummercourseinlocalcommunitycollege(1courseineachof2sessions)andthencontinueincommunitycollegetaking2coursesinfalltermand3or4inspringterm,thenreviewoptionsforschoolingfollowingyear.
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Targetsaddressedduringtherapy(action,notjusttalk)
• Gotointerviewwithadvisoratcollegeforcourseselection&plan• Rehearseanswerfor“whyaren’tyouawayatcollege?”• Volunteerasanadvisorforhighschoolroboticsclub• Challengeavoidanceofseekingoutstudygrouppartners(“fearvsbiggerfear”).Approachtoinviteandgetnamesandcontactinfo)
• Rehearsalofhowintroduceselftootherstudentsandaskiftheywouldbeinterestedinformingastudygroup
• GotoseeTAandprofessortoseekhelpwithspecificquestionsorproblemsets,evenifhelpnotreallyneeded
• “Makemyroommoreliveable,cleaningoutfromhoarding”• “Joinengineeringclubatcollege”
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Supportforwritingproblem(writtenexpressiondemandsmoreEF)
• Bringsyllabiforallcoursesandidentifywritingassignments• Discusseachwritingassignmentandbringinmaterialstoberead• Dosomeworkinsessionidentifyingkeyideasfromreadingsthataretobewrittenabout
• Learntouse“Webspiration Prosoftware”toorganizeideasforpaper• Bringinitialdraftofpaper tosessionforcritique• Identifyareaswheremoreelaboration ofideasisneeded• Encourageduseofwritingclinicatschoolandmeetingwithprofswhilewritingisinprogress.
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Progressreport
• “I’vedecidedthatmyaddictiontowatchYouTubeisrelatedtoissuesmyparentsargueparentsargue,about…whenIgetnervous.”
• “IavoiddealingwithpeoplebecauseIfearrejection.Amafraidpeoplejustwon’twantmearound.”
• (Exampleoffeelingrejected?)9th gradeIlikedagirlandspenttimewithherfor2yrs,thenitdidn’tworkout.Wasverypainful.”
• “Iwascold,distant,andunemotional,likemyfather.Butnowmycomfortzonehasbeenexpanding,nowIcanstartaconversationanddosomesmalltalk.”
• Gradesaremostlygood,thoughImayfailCalc 2andneedtoretake.”
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Post-secondaryEmploymentforyoungpeoplewithADHD/Asperger’s
• Jobsearchisusuallyterrifyingandfrustrating(supportisneeded)Onthejob:• thosewithAspergers oftenhaveimportantstrengths:
reliable,persistent,technicallyable,knowledgeable,accurate,logical
• Yettheyalsomayhavesomesignificantdifficulties:teamworkskills,copingwithchange,fittinginwithco-workers,askingforhelp,acceptingadvice(Atwood,2007)
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Preparationfortransitionshouldbegininearlyadolescence• Henryaverybrightboyin8th gradehadgoneonstrikerefusingtodoassignedworkinhisspecialed andco-taughtclasses,frequentlegalisticargumentsaboutteachersnotrespectinghisrights,oftenheadondeskthroughoutclassperiod.
• Initialvisits:noeyecontact,weakhandshake,laydownandcurleduponcouch,wincedwhenmychairsqueeked,reluctanttorespond
• “IhateschoolandIhavenorealfriends.”“TheteacherskeeptellingmethatI’mverysmart,buttheytreatmelikea4th grader.I’mnotgoingtodowhattheytellmeuntiltheystarttreatingmealotbetter.”
• GaveIQtest:scoredinthesuperiorrange.Seeingresults,hesaid,“Ok,IknowI’msmart,butIreallyambroken”
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ElementsofthisIntervention
• Listenempathicallytopatient’sviewofhiscurrentsituation• Startmedicationtoreduceanxiety(FLU10->20)• Testtoidentifystrengths• TeachpatientaboutADHD,socialanxietyandemotionalIQ• ReintroducestimulantforADHDcautiously (SBC,rebound)• Confront maladaptivebehaviorsinspecificsofpresentinteraction• Designandencouragemoreadaptiveresponses• Supportpersistentefforttoworktowardgoal(outofspecialed)
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2ImportantTypesofIntelligenceRationalintelligence:logical,evidenceandfact-basedintelligence
Emotionalintelligence:psychological,emotion-basedintelligence
Rationalintelligencerecognizesneedtopayattentiontotheirrational(EIQ)
Emotionalintelligenceisnotaspredictableasrational—oftenmorecomplex,withmoreexceptionse.g.whyisajokefunnyinsomesituations,butnotinothers?
Someneedtousetheirrationalintellecttounderstandsomeimportantpsychologicalfactors thatmostotherspickupjustbywatchingandlistening.
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TeachingEmotionalIntelligence
Empathize,butfocusonspecificsofpresentsituation,thengeneralizehandshake,eyecontact,limpfishlyingdownoncouchcurlingupnotrespondingtoquestionsleavingittomothertoanswercomplainingaboutmysqueeking chairblamingothersforwhateveriswrongassumingequalstatusandpowerwithadults,esp teachersignoringtheoryofdifferentminds,notallaboutyou
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KeyPoints
• Recognize subtle,complex,butmassivedifficultiesintransitionforeveryone,especiallythosewithADHDand/orAsperger’s
• Don’tunderestimatethepowerofsocialanxietytodisrupttransition• Utilizemedications whenneededforADHDand/oranxiety• Identify individualstrengthsandalsovulnerabilities• Utilizeempathywithconfrontation• Teach emotionalintelligenceinspecificsofinteraction• Teachskillsandpressforactionstopracticethem• Reinforcesuccessesandsupportpersistence,esp infailures