EFinYoungPeoplewithADHDand/orAsperger’s

duringtheirPost-SecondaryTransition

ThomasE.Brown,Ph.D.

Director,BrownClinicforAttention&RelatedDisorders,Hamden,CTClinicalAssociateProfessorofPsychiatry&BehavioralSciences

KeckSchoolofMedicineUniversityofSouthernCalifornia

A New Understanding of ADHD

ADHD = developmental impairment of the brain’s management system, its executive functions.

(Brown, 2005, 2006, 2013)

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?

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)

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)

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.

Scaffoldingmay support or undermine executive functioning

¨Parents¨Siblings¨Teachers¨Friends (peers and adults)¨Extended family¨Physician, counselor or therapist

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

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

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

•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

James– 23yo collegestudent

• Graduatedhighschoolwith3.6GPA• Enteredacompetitiveuniversityasengineeringstudent.Didwellinmathcourses,butstruggledwithwritingessaytestsandpapers

• Avoidedattendingclasswhenpapersweretobehandedin,thenfeltunabletoresumeclassattendanceorcontactprofessororTAorlearningcenterbyemail,phoneorofficehoursvisit

• Wasputonacademicprobation• Tookvoluntaryleaveofabsenceandfoundajob• Soughttreatment1-1/2yrs afterleavingcollege—wantedtoreturn

James(2)

• Initialconsult:handsome,well-built,articulate,abitshy,wantedtoreturntouniversitybutfeltneedtodealwithhisproblemswithwriting,difficultieswithreadingcomprehensionandrecall,andshynessabouttalkingwithfacultyorTAs. FatherdescribedJamesassomewhatshyinchildhoodandadolescence,butnoproblemswithschoolattendanceorgettingworkdone.Someparticipationinyouthsportsleagues,but“notsupersocial”,“tendstopullintohisshell”.

• Currentlylivingwithgirlfriendwhodominatedanddependedonhiminapartmentpaidforbyparents3hoursfromawayfromparentsinthecitywherehehadbeenattendinguniversity.Hadjustendedjobduetocompanymoving.Noabuseofdrugsoralcohol.

ImpressionsandRecommendations

DX:ADHDwithSocialAnxietyDisorder• Educatedpatientandfatherre:diagnosesandnatureofphobia• Recommendedcognitivebehavioraltherapyincitywherehewascurrentlylivingwithgirlfriend.Initialtarget—getanotherjob.Longertermgoal—increaseabilitytodealwithfacultyandstaffre:school

• RecommendedLDXwithstartofFLUafterLDXdosestabilized• ReferredfortreatmentofADHDandtutoringtodealwithwritingproblem

• Supportedhiswishtoreturntoschool,butsuggestedstartingfirstwithjustonecourseinlocalcommunitycollege.

Arthur19yo collegestudent

• Camewithbothparentsafterbeingterminatedendof1st yearfirstyearofstudyinhonorsengineeringprogramatcompetitivestateuniversityduetolowgrades

• Hadbeenhonorstudentinhighschool,participatedinroboticsclubandcontinuedactivityinBoyScouts.Limitedsocialcontactsoutsideofschool.

• Hadbeenseenbymeinitiallywhen8yo—diagnosedasADHDwithAspergers.StartedonATX(helpfulat80mgqam).Seemedtobedoingwelluntil8th gradewhenaddedLDX40+Dex 10boostertosupportEFandhomework.Respondedwell,parentssupportive,nofurthercontactuntilendof1st yr college.(noprepfortransition)

Initialpresentation

• Tall,thin,tense-looking,limitedeyecontactexceptwhenaddressed,dressedinbaggyjeans,hairpulledbackinponytail,spokerapidly.

• “FoundcollegewasreallydifferentfromhighschoolwhereIwasusedtotheplaceandthepeople.Itwasreallyhardtogetusedto.”

• “Didn’ttellmyparentsIwashavingtroubleuntilendofyearwhenIknewIwouldnotbeabletoreturn.Wastooembarrassedtotell.”

• “I’mextremelynervoustalkingwithotherpeople”• “Wenttoclasses,butmostlykeptinmyroom,hadnofriends”• “Lotstroublewritingpapers,buttooafraidtogotowritingclinic”

ImpressionandRecommendations

• Socialanxiety,ADHD,dysthymia,Asperger’sDisorder• ContinueATX80mg,LDX40mg,Dex 10mg,AddFLU10->20• PsychotherapywithCognitiveBehavioralfocusx1q2weeks• Encouragedparentstopushhimtodomoresocialinteractions,e.g.gotostores,makephonecalls,settingupstudygroups,drivingself

• Continuetoliveathomewhilestartingsummercourseinlocalcommunitycollege(1courseineachof2sessions)andthencontinueincommunitycollegetaking2coursesinfalltermand3or4inspringterm,thenreviewoptionsforschoolingfollowingyear.

Targetsaddressedduringtherapy(action,notjusttalk)

• Gotointerviewwithadvisoratcollegeforcourseselection&plan• Rehearseanswerfor“whyaren’tyouawayatcollege?”• Volunteerasanadvisorforhighschoolroboticsclub• Challengeavoidanceofseekingoutstudygrouppartners(“fearvsbiggerfear”).Approachtoinviteandgetnamesandcontactinfo)

• Rehearsalofhowintroduceselftootherstudentsandaskiftheywouldbeinterestedinformingastudygroup

• GotoseeTAandprofessortoseekhelpwithspecificquestionsorproblemsets,evenifhelpnotreallyneeded

• “Makemyroommoreliveable,cleaningoutfromhoarding”• “Joinengineeringclubatcollege”

Supportforwritingproblem(writtenexpressiondemandsmoreEF)

• Bringsyllabiforallcoursesandidentifywritingassignments• Discusseachwritingassignmentandbringinmaterialstoberead• Dosomeworkinsessionidentifyingkeyideasfromreadingsthataretobewrittenabout

• Learntouse“Webspiration Prosoftware”toorganizeideasforpaper• Bringinitialdraftofpaper tosessionforcritique• Identifyareaswheremoreelaboration ofideasisneeded• Encourageduseofwritingclinicatschoolandmeetingwithprofswhilewritingisinprogress.

Progressreport

• “I’vedecidedthatmyaddictiontowatchYouTubeisrelatedtoissuesmyparentsargueparentsargue,about…whenIgetnervous.”

• “IavoiddealingwithpeoplebecauseIfearrejection.Amafraidpeoplejustwon’twantmearound.”

• (Exampleoffeelingrejected?)9th gradeIlikedagirlandspenttimewithherfor2yrs,thenitdidn’tworkout.Wasverypainful.”

• “Iwascold,distant,andunemotional,likemyfather.Butnowmycomfortzonehasbeenexpanding,nowIcanstartaconversationanddosomesmalltalk.”

• Gradesaremostlygood,thoughImayfailCalc 2andneedtoretake.”

Post-secondaryEmploymentforyoungpeoplewithADHD/Asperger’s

• Jobsearchisusuallyterrifyingandfrustrating(supportisneeded)Onthejob:• thosewithAspergers oftenhaveimportantstrengths:

reliable,persistent,technicallyable,knowledgeable,accurate,logical

• Yettheyalsomayhavesomesignificantdifficulties:teamworkskills,copingwithchange,fittinginwithco-workers,askingforhelp,acceptingadvice(Atwood,2007)

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”

ElementsofthisIntervention

• Listenempathicallytopatient’sviewofhiscurrentsituation• Startmedicationtoreduceanxiety(FLU10->20)• Testtoidentifystrengths• TeachpatientaboutADHD,socialanxietyandemotionalIQ• ReintroducestimulantforADHDcautiously (SBC,rebound)• Confront maladaptivebehaviorsinspecificsofpresentinteraction• Designandencouragemoreadaptiveresponses• Supportpersistentefforttoworktowardgoal(outofspecialed)

2ImportantTypesofIntelligenceRationalintelligence:logical,evidenceandfact-basedintelligence

Emotionalintelligence:psychological,emotion-basedintelligence

Rationalintelligencerecognizesneedtopayattentiontotheirrational(EIQ)

Emotionalintelligenceisnotaspredictableasrational—oftenmorecomplex,withmoreexceptionse.g.whyisajokefunnyinsomesituations,butnotinothers?

Someneedtousetheirrationalintellecttounderstandsomeimportantpsychologicalfactors thatmostotherspickupjustbywatchingandlistening.

TeachingEmotionalIntelligence

Empathize,butfocusonspecificsofpresentsituation,thengeneralizehandshake,eyecontact,limpfishlyingdownoncouchcurlingupnotrespondingtoquestionsleavingittomothertoanswercomplainingaboutmysqueeking chairblamingothersforwhateveriswrongassumingequalstatusandpowerwithadults,esp teachersignoringtheoryofdifferentminds,notallaboutyou

KeyPoints

• Recognize subtle,complex,butmassivedifficultiesintransitionforeveryone,especiallythosewithADHDand/orAsperger’s

• Don’tunderestimatethepowerofsocialanxietytodisrupttransition• Utilizemedications whenneededforADHDand/oranxiety• Identify individualstrengthsandalsovulnerabilities• Utilizeempathywithconfrontation• Teach emotionalintelligenceinspecificsofinteraction• Teachskillsandpressforactionstopracticethem• Reinforcesuccessesandsupportpersistence,esp infailures