Social Skills Training and ADHD: What Gives it the Best Shot at Working?

A short supply of self-restraint and other characteristics of ADHD can hurt relationships.  Social skills training is one of the interventions used to prevent relationship damage and increase relationship repair.  But does it work?

The results of a fresh-off-the-presses study on social skills training support Russell Barkley’s argument (Understanding ADHD) that skills presented and practiced away from real-life situations at the moment of trouble (e.g., as one is about to curse someone out) may be of little value.

Social skills training had “limited efficacy” according to Canadian researchers reviewing social skills training for kids and teens with ADHD (study here).  Nonetheless, they identified “two promising” ways to increase its usefulness.  First, offer “increased reinforcement and reminders of appropriate social behavior at the point of performance to youth with ADHD (e.g., in vivo, in real life peer situations as opposed to in the clinic).”  Second, encourage “peers to be more socially accepting and inclusive of youth with ADHD.”

In other words, go to the youths’ environments to work on what’s happening there (looking at both their actions and the actions of others toward them).

Maybe some day, we’ll send kids to mental health clinics less often and start going to them, where the action is.  And where science suggests we need to be.

The Multiple Faces of ADHD

When I run my ADHD group, I start off with an orientation that includes sharing how complex ADHD really is.  And one of the things that surprises most group members is hearing that ADHD is actually seen as multiple conditions.  And I’m talking about something bigger than whether one’s diagnosed as having a “presentation” of ADHD as primarily inattentive, primarily hyperactive or a mix of both.    grid-2111788_1920

As Joel Nigg at OHSU puts it, ADHD appears to be an “umbrella diagnosis,” such as cancer once was (see here).  Cancer was thought to be a single disease, and we now know there are various types of cancer.

Researchers are currently trying to identify the various conditions found under the umbrella of “ADHD.”  Each may have different genes, environmental causes, and clinical outcomes.  They likely have different brain signatures (see Understanding ADHD for more on brain differences).

And they may have different optimal interventions.

This complicates research findings that include participants only because they share a diagnosis of ADHD.  It might be like trying to understand cancer by averaging results across participants with skin cancer and liver cancer.  Or perhaps it’s more analogous to averaging results across participants with different forms of skin cancer.  It’s unclear.

Once the fog clears, I’m excited to know what we’ll learn about the different conditions all now diagnosed as simply ADHD (with three “presentations”).

 

 

How to Make ADHD worse

When you have ADHD, here’s your recipe for disaster:  Mix sleep deprivation with carnival food.  Deep fry.

Hold the physical exercise and Omega-3s.

No one says, “I want to be my worse self.”  Yet many of us are doing exactly what we need to get us there or keep us there.

When you have ADHD, sleep deprivation makes your symptoms worse, carnival-like food makes your symptoms (particularly forgetfulness) worse and lack of physical exercise and Omega-3s keeps them from getting better.

If you want to give yourself the best chance at optimal brain functioning, here’s the winning combination:  sleep enough, eat healthy food (including Omega-3s), and exercise regularly.  This is true for all us but is essential when you have ADHD.

Consider that chronic sleep deprivation looks like ADHD.  Combine them and you have more extreme ADHD.  Check out recent research on ADHD and circadian rhythms here.

Omega-3s matter so much, there’s even an Omega-3 prescription for ADHD called Vayarin.  See specifics on the Omega-3 and ADHD connection here:  Something Fishy.

For a recent review and meta-analysis on use of Omega-3s for ADHD, go here.

As for exercise, namely cardio exercise, check out this recent review.

Try the winning combination for even just one week and see what you notice.  I bet your brain will thank you.

Understanding ADHD

Per Russell Barkley (RB), ADHD guru (i.e., scholar and scientist):

ADHD is a disorder of self-regulation that can also be described as a “disorder of age-inappropriate behavior” that looks like inattention and lack of inhibition.

Though I want to clarify that the inattention depends on what you are doing; another guru of ADHD, Thomas Brown, says the “central mystery” of ADHD is that those with it can pay attention to some things and seem incapable of paying attention to other things.white-matter-fibers-hcp-dataset-red-corpus-callosum

But back to RB and ADHD as a disorder of self-regulation.

RB defines self-regulation as “self-directed action intended to alter subsequent behavior so as to change the probability of a future event or consequence” (to improve your longer-term welfare).

For example, say you have a problem with money and keep getting into debt by living off credit.  You want to pay off your debt (self-directed action) to be able to cancel your credit card and limit spending (subsequent behavior) to reduce the chance you’ll get into debt again (change the probability of a future event).

Where does ADHD fit? With ADHD one has the intention to alter behavior (e.g, limit spending) to change the future (e.g., live debt-free) but struggles with the self-directed action (e.g., paying off debt) required for this.

Barkley says it’s a disorder where knowledge fails to guide performance.  You know what to do but struggle to do it.

WHY?

RB highlights that ADHD brains show prefrontal cortical network differences (these networks are responsible for Executive Functioning and self-regulation is the core of Executive Functioning).  Here is where the differences exist and what comes into play:

  • Frontal-striatal circuit, the “what” network (what we think influences what we do) Here lives…
    • Freedom from distraction
    • Working memory
    • Organization and planning
  • Frontal-cerebellar circuit, the “when” network (timing of thought, behavior)
    • With ADHD, there’s “time blindness,” and
    • A “myopia to the future”
  • Frontal-limbic circuit, the “why” network.  Here lives…
    • The decision-maker of the brain (if you have multiple goals, which do you pursue? this circuit, as RB puts it, “makes the final call”)
    • Motivation
    • Emotional control or dyscontrol

These network differences show up as self-regulation differences that encompass

Self-directed action, Self-awareness, Self-motivation, Self-directed attention, Self-restraint, Self-directed sensing, Self-directed emotions, and Self-directed play.

WHAT TO DO?

Outsource these brain functions.  RB calls this externalizing the brain functions where there are deficits.  For example, he says, use “artificial prosthetic cues to substitute for working memory deficits.”

Ideally, this is what ADHD coaches will help you do (for more on this, see Does ADHD Coaching Work?)

Here are some pointers for externalization:

  1. Per RB, the externalization of brain functions is needed at the point of performance and within your natural setting (e.g., if you struggle to write a report at work, you need external factors to guide your attention at work at the time you need to write); and
  2. To externalize, change your environment (think planners, alarms, points, signs).

Replenish your self-regulation (think self-control) resource pool.  It’s depleted by simple use as well as stress, drug abuse, illness.  Replenish through

  • Rewards, positive emotions
  • Positive self-talk
  • 10 minute breaks between tasks requiring self-control
  • 3 minutes of relaxation or meditation
  • Glucose ingestion (Gatorade, lemonade, sugar water) while working on tasks requiring self-control
  • Daily physical exercise

Also, break lengthy or complicated tasks down.  One of my favorite reminders of this, though I really like elephants, is, “How do you eat an elephant?”

Answer:  one bite at a time.

RB adds that accommodations or scaffolding and the compassion and willingness of others to make accommodations are “vital” to your self-regulation effectiveness.

Sources:  Two talks by Russell Barkley on ADHD, one from 2013 entitled, “The Importance of Emotion in Understanding and Managing ADHD (here) and one from 2012 entitled, “ADHD, Self-Regulation, and Executive Functioning:  Theory and Implications for Management” (the part of it I used is here).

Hello Stars, My Old Friends

This past weekend I attended a workshop on gratitude and joy at Esalen Institute on the coast of California near Monterey.

In the deep darkness, I looked up at the stars and felt awe and sadness as I noticed constellations I had long forgotten.  It’d been several years since I’d seen them and I remembered how much I once loved them and loved space…knowing our world is much bigger and we much smaller than we usually acknowledge.  20141026_d7000web_4604

The stars, when I can see how numerous and bright they are, remind me to focus on what really matters…our connections to each other however far apart we are.  We all love, we all suffer, and we all have the light of stars showing through, or beyond, the deep darkness above us.

This weekend, I am grateful for the stars, the deep darkness that let me see them, and for the reminder that they have been there all along.  For all of us.

P. S. James and Jane Baraz led the workshop.  James is co-author of Awakening Joy (link is to his blog).

 

Stuck On Your Carousel?

I have long loved carousels and, for some reason, began to love them even more after reading Ray Bradbury’s Something Wicked This Way Comes.  I find them enchanting.

But when I get stuck going round and round riding the same beast (or moving from one to another on the carousel), I know it’s time to get off it.

How does anybody do this? First you have to notice that you’re on your carousel. carousel_paris This means identifying what’s on it.

What thoughts, emotions, etc. are the beasts that call you to it? If you have ADHD, these may include boredom, frustration, the thought “Why bother?” or “I’ll do it later.”  Once you jump on one of these beasts, what does going round and round look like for you? Watching movies, playing video games, going online? Nothing wrong with these things.

If you know, though, that one round on the carousel is likely to lead to many others without your even noticing while it’s happening, consider seeing your carousel from a distance.

When you are off it, go ahead and try to create a visual of your carousel, including what thought, emotion, memory, etc. each beast represents and what behavior follows.  Then when you jump on your carousel, you have a better chance of noticing this and choosing whether to keep riding or step off.  And, unlike the poor souls of Bradbury’s story, you’ll be only minutes or hours older.

 

To get things started, add sugar…a spoonful or more

Just the other day, my husband played this song to our daughter, and I said, “Hey, Mary Poppins had it right.”  As a mental health therapist running groups for adults diagnosed with ADHD, I encourage members to have fun with their tasks as much as possirestaurant-coffee-cup-cappuccinoble.  Turn up the pleasure, excitement, interest.  Some will work outside or somewhere they find pleasant, some pair a reward with tasks and some work with others, even just as company.  Some do all of these.

If you struggle to start something, remember Mary Poppins.  And that some of us need a little more sugar than a spoonful.

 

“It’s like a room full of puppies and candies.”

ADHD infoChildren often say it best.

My child said this as he heard me speaking about ADHD.

I asked him what he meant, and he said it’s what a room seems like to him.  I asked him what an empty room seems like, and he described how he will notice the shapes, curves, and corners of the walls; bumps on the ceiling; light seeping under the door; and the texture of the floor, adding that carpet’s like a maze of threads.  He concluded, “Even an empty room is filled with so much.  It’s insane.”

 

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