Essential Ideas for Parents

给父母的核心要点 拉塞尔·巴克利博士（Dr. Russell Barkley）对注意力缺陷多动障碍（ADHD）进行了重新定义，指出它并非注意力不足或社会环境的副产品，而是一种涉及行为抑制、执行性自我调节以及时间盲症的严重神经遗传性障碍。他解释道，ADHD患者在执行年龄上存在约30%的发展迟缓，导致他们在“知道该做什么”与“随着时间推移去执行”之间存在持久的脱节。由于ADHD是一种执行障碍而非知识匮乏，干预措施不能依赖口头说教或脱离实际场景的训练，而是需要持续的、在“表现发生点”提供的外部辅助支架、即时问责机制，以及类似于管理慢性糖尿病的环境调整。巴克利强调，药物治疗通过直接调节多巴胺转运蛋白基因，是单一最有效的干预手段；同时他敦促父母树立“牧羊人”而非“工程师”的心态，用科学倡导和相互宽恕来取代看护者的内疚感。 ADHD在本质上是一种自我调节与执行抑制方面的神经发育障碍，而非单纯的注意力缺陷，其遗传率高达80%至91%，与人类身高的遗传度相当。 (21:47) 患有ADHD的儿童在执行功能上平均存在30%的量化滞后，这意味着责任分配、成长里程碑以及支持措施必须根据其实际的执行年龄而非生理年龄来进行校准。 (103:16) 有效的行为管理需要在“表现发生点”直接提供持久的外部辅助和即时问责，因为ADHD阻断了储备知识向实际表现的转化。 (78:34) 药物治疗是最有效的一线干预手段，在药效持续期间通过直接调节多巴胺和去甲肾上腺素，能够使55%至65%的儿童执行功能恢复正常。 (159:22)

Dr. Russell Barkley argues that ADHD is fundamentally an executive function and self-regulatory disorder characterized by neurodevelopmental delays, requiring caregivers to abandon verbal moralizing and build permanent, prosthetic environments at the point of performance. ADHD as Executive Dysfunction and Emotional Impairment (5:01) ADHD is fundamentally misnamed; the initial failure to emerge in preschool years is behavioral inhibition rather than inattention. This manifests as motor impulsiveness that gradually recedes into subjective adult restlessness, cognitive impulsiveness, and emotional disregulation. Dr. Barkley notes that historical literature dating back to Alexander Crichton's 1798 textbook treated emotional impulsiveness as an intrinsic core feature until the DSM mistakenly demoted it to an associated feature. Unlike mood disorders that over-generate affect, ADHD represents a deficit in self-regulating normal emotional states, which impairs intrinsic motivation and leaves individuals dependent on immediate environmental reinforcement. The attentional deficit in ADHD is an executive failure comprising poor persistence, motor disinhibition to distractions, and working memory deficits rather than generalized inattention. Dr. Barkley outlines self-regulation across internal abilities: the pause (inhibition), the mind's eye (visual hindsight and foresight), the mind's voice (internalized private speech for following rules), and the mind's heart (emotional self-motivation). Under serial brain imaging, children with ADHD exhibit a two- to three-year maturational delay in prefrontal cortex networks while the motor strip develops early, producing spontaneous activity without inhibitory control. Genetic Architecture, Biological Etiology, and Debunked Myths ADHD symptoms demonstrate an 80% to 91% heritability rate in twin studies—comparable to height—while shared family environment accounts for 0% of trait variance. Around two-thirds of cases are directly inherited, involving dopamine regulation genes, whereas roughly one-third are acquired through non-genetic disruptions such as prenatal environmental insults, postnatal localized brain trauma, central nervous system infections, or streptococcal autoimmune reactions affecting basal ganglia circuits. Gene-environment interactions also multiply risk; combining two genetic risk factors with prenatal maternal smoking increases ADHD risk eightfold. Dr. Barkley dismisses widespread claims that social factors, screens, diet, or poor parenting cause ADHD. There is no empirical evidence that digital media shortens human attention spans; individuals with ADHD simply gravitate toward rapidly paced stimulation. Dietary interventions like artificial additive elimination benefit only about 5% of young children, and omega-3 supplements yield modest effects largely restricted to sluggish cognitive tempo (SCT) or pure inattentive presentations. SCT itself represents an accuracy disorder linked to internal anxiety and learning deficits, distinct from ADHD's productivity impairments. Prosthetic Interventions at the Point of Performance (78:34) Because ADHD is a performance disorder rather than a lack of knowledge, clinical skill-training outside the natural setting repeatedly fails. Dr. Barkley stresses that interventions must target the "point of performance"—the exact classroom or domestic context where behavior occurs. Behavior modification in ADHD does not instruct unknown skills; instead, it provides permanent motivational prostheses through frequent, immediate contingencies that should never be removed. Treatment functions like insulin in diabetes, managing symptoms continuously to prevent compounding functional consequences rather than curing the underlying condition. Time perception is severely disrupted in ADHD, dismantling an individual's ability to assemble hierarchical behaviors over extended time horizons. Management requires building "Event-Response-Outcome" (ERO) bridges that break distal targets into immediate units, externalizing working memory via tactile manipulatives or index cards, and replacing verbal lecturing with prompt actions ("act, don't yak"). For examinations, Dr. Barkley recommends "time off the clock"—allowing students to pause a standard-duration timer for physical or mental breaks—rather than conventional extra time, which he characterizes as agonizing for children with impaired time perception. Developmental Scaffolding, Adult Risks, and Long-Term Pharmacotherapy (101:51) Under the developmental "30% rule," executive age lags roughly 30% behind chronological age. Consequently, a 16-year-old possesses the self-regulation of an 11-year-old, demanding adjusted expectations around driving, college autonomy, and childcare duties. Untreated impulsivity across adolescence leads to a tenfold rise in teen pregnancies—with longitudinal data showing 32% of boys fathering a child and 68% of girls becoming pregnant by age 19—as well as elevated rates of sexually transmitted diseases, financial instability, and marital dissolution. Pharmacotherapy directly addresses the neurogenetic shortfall, with over 400 placebo-controlled trials establishing a 55% to 90% response rate for stimulants and non-stimulants. For 55% to 65% of children, medication temporarily erases the 30% developmental gap while pharmacologically active. Dr. Barkley dispels assertions that therapeutic stimulants induce addiction, cause seizures, or generate aggression. Meanwhile, unproven treatments—such as chiropractic skull manipulation, play therapy, and commercial working memory training programs that exhibit short-term gains but cognitive atrophy within three months—should not replace medical care. Ultimately, caregivers must adopt an authoritative, expert advocacy role while maintaining emotional acceptance and daily forgiveness. Dr. Barkley concludes that ADHD requires lifelong chronic management across home and educational settings rather than short-term curative therapies. Successful outcomes depend on caregivers and educators serving as proactive external frontal lobes, structuring environments to match an individual's executive age while utilizing evidence-based pharmacotherapy to mitigate adverse adult trajectories.

Russell Barkley博士指出，注意力缺陷多动障碍（ADHD）本质上并非单纯的注意力不集中或信息匮乏，而是一种高度遗传的神经发育与执行功能障碍，其核心缺陷在于行为抑制受损、情绪调节失控以及无法在时间维度上组织行为。 ADHD的核心是抑制障碍与情绪失控 (5:01) ADHD被严重误称，其最早在学龄前出现的首发缺陷其实是行为抑制障碍，而非注意力问题。这种抑制失败早期表现为运动过度与认知冲动，随着年龄增长，躯体多动逐渐内化为主观上的精神烦躁，因此多动在成人诊断中并无独立价值。此外，自1798年Alexander Crichton的文献记载至现代神经科学，情绪冲动始终是该障碍的核心组成部分。DSM手册将情绪症状剔除为“相关特征”被Barkley视为严重失误。ADHD患者并非情绪生成异常（如心境障碍），而是大脑缺乏自我平复、自我安抚与抑制即时情绪反应的自我调节能力。 执行功能受损阻断时间组织与内在动机 (16:19) ADHD的注意力缺陷主要体现为三大执行缺陷：无法朝目标持久坚持、对外界干扰缺乏运动抑制，以及工作记忆衰退。自我调节依赖于行为暂停、头脑视象（后见之明与远见）、内在言语以及情绪调节（心智之心）。因为情绪是驱动人类动机的引擎，无法管理情绪直接导致患者丧失内在自主动机。这解释了为何ADHD儿童可以连续数小时沉迷于提供即时反馈的电子游戏，却无法在缺乏即时结果的纸笔作业上坚持数分钟。患者只生活在“此时此刻”，无法在较长的时间跨度中建立复杂的层级化行为，使得日常生活变成一连串本可预防的危机。 生物学机制驳斥社会环境致病论 (51:58) 双生子研究表明，ADHD症状的个体差异有80%至91%归因于遗传变异，其遗传率与人类身高相当，共同抚养环境对该特质变异的贡献率为0%，彻底推翻了“不良家教导致ADHD”的迷信。虽然约三分之二为直接遗传，但约三分之一可由产前不良环境或产后中枢感染、铅中毒及免疫系统分子模拟等非遗传生物侵害引起。多中心脑成像研究证实，患者前额叶的发育滞后2至3年，而运动皮层反而可能早熟2至3年。目前已定位多个与多巴胺相关的候选基因（如DAT1），且基因与环境毒素（如孕期吸烟）的交互作用会使患病风险剧增8倍。相比之下，饮食添加剂仅对约5%的儿童产生轻微影响，电子屏幕与现代媒体亦非病因。 干预应立足表现点并构建假肢式环境 (78:34) 由于ADHD是“表现障碍”而非“技能缺失障碍”，在诊所或夏令营传授社交技巧无法迁移至现实生活。干预必须发生在问题发生的“表现点”（如课桌或操场），通过建立外在“假肢式环境”来提供缺失的动机。ADHD儿童的执行年龄约为其实际生理年龄的70%（即30%延迟规则），要求一名16岁患者驾驶或让14岁患者照看婴儿，相当于将责任交给11岁或9岁的儿童。因此，家长必须从说教转向行动（“Act, Don't Yak”），缩短事件、准备反应与结果之间的时空跨度（构建ERO桥梁），并将考试延时调整为允许中途暂停秒表休息的“非计时休息（time off the clock）”。 科学用药与照料者的理性倡导角色 (134:16) 单纯的行为干预仅能使约三分之一的儿童免于用药，临床上66%至80%的患者最终需要药物支持。规范服用中枢兴奋剂不会导致成瘾或暴力攻击，也不会在治疗剂量下引发癫痫；若诱发抽动，停药一周内即可逆转。药物能够暂时弥合55%至65%患儿的30%执行发展落差，但在药效消退后缺陷依然存在。Barkley强调，ADHD的管理应类比为糖尿病的胰岛素治疗，目标在于预防诸如青少年怀孕（风险增加10倍）、性病传播及成年期财务和婚姻破裂等灾难性次生伤害。家长必须成为通晓科学证据的专家，在学校会议中主导倡导，并彻底摒弃将ADHD浪漫化为“天赋”的幻想。 Barkley总结指出，ADHD是一种伴随一生的神经发育障碍，无法被彻底根治，认知训练（如Cogmed）的效果亦会在停训后衰退。抚养ADHD儿童意味着父母必须全天候充当外部“替代前额叶”，这一极其繁重的过程需要家长主动践行自我宽恕，并不带怨恨地接纳孩子的生物学局限。

## Detailed walkthrough ### [00:13](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=13s) 演讲缘起与讲座的核心初衷 罗素·巴克利博士（Dr. Russell Barkley）在开场时提到，海蒂（Heidi）邀请他来做这场演讲，这让他深感荣幸与感激。面对台下以 ADHD（注意缺陷与多动障碍）患儿家长及亲友为主的听众，巴克利博士一直在思考该分享些什么。海蒂希望他能带来一些全新且与众不同的内容，于是巴克利博士坐下来反思：“如果一个家庭来到我们的诊所就诊，在完成所有的评估和咨询辅导之后，我希望他们带走的核心理念究竟是什么？” 他最初试图将这些理念浓缩成 10 条，但发现根本做不到；即便精简到 30 条也相当困难，因为还有另外 30 条被迫舍弃。巴克利博士将这 30 条视为基石般的关键概念。他强调，如果一个家庭真正想理解孩子所患障碍的本质，以及如何成功抚养与应对这样的孩子，就必须理解这些理念。由于他从未以这种形式开展过演讲，他打趣地表示大家可以一起来体验这种全新的方式，听完之后大家甚至可能会劝他“以后别再这么讲了”。 ### [01:27](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=87s) 理念一：ADHD 是一种发育障碍而非心理病理学异常 巴克利博士切入第一个核心理念：认识这一障碍。ADHD 本质上是一种发育障碍（Developmental Disability）。所谓发育障碍，是指个体表现出与其年龄不相符的行为，但这并不意味着个体的行为属于病理学异常（Pathological）。换言之，ADHD 与正常人群之间的差异是“量变”（Quantitative）而非“质变”（Qualitative）。 ```mermaid flowchart TD accTitle: 发育障碍与心理病理学的本质区别 accDescr: 对比 ADHD 这类发育障碍与精神分裂等心理病理学异常的核心差异 subgraph DevDisorder["发育障碍 (如 ADHD)"] direction TB D1["正常心理特质的发育速率迟缓"] D2["经历相同的发育阶段，但时间严重滞后"] D3["与普通人呈量变差异（如身高、运动能力的高低）"] end subgraph Psychopathology["心理病理学异常 (如精神分裂/双相障碍)"] direction TB P1["行为与心理状态的严重畸变"] P2["无需依据年龄调整诊断标准"] P3["属于质变差异，任何年龄段均表现为严重异常"] end ``` 巴克利博士将发育障碍与心理病理学（Psychopathology）进行了严格区分。严重的精神病理状态——例如双相情感障碍、精神分裂症、重度抑郁症或孤独症——属于极其严重的异常，在任何年龄段都能被一眼识别，诊断时无需因年龄去大幅调整标准。然而，发育障碍仅仅是某种正常特质的发育速率迟缓。患有 ADHD 的儿童会经历与常人相同的成长阶段，只是出现的时间大幅滞后。这种特质通常要到 30 岁出头才会最终成熟，而 ADHD 患者即便发育平稳成熟，其最终达到的水平仍将远远落后于普通人群。因此，“延迟”并不等于暂时的“滞后”，而是一种慢性的长期滞后。 巴克利博士在此痛批了市面上那些迎合家长的畅销书观点： - 那些书籍宣称 ADHD 患儿是“与普通人存在本质差异的物种”，将他们比作“必须与农夫一起上学的幼小猎人”，或是声称“ADHD 是普通孩子所没有的天赋与礼物”。 - 巴克利博士直截了当地斥责：“This is nonsense. This is utter gibberish. There never was nor will be any science that would support those ideas.”（这是胡说八道，纯粹的废话。过去没有任何科学能支持这些观点，将来也绝不会有。） - ADHD 绝非人类存在的某种独特“质变状态”，它与常人的区别就像个子的高矮、写作能力的强弱、语言或运动天赋的高低一样，纯粹是程度上的量变。如果不认清这一点，就会将患者污名化为“来自金星或火星的外星人”。 ### [05:01](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=301s) 核心受损特质之一：抑制力缺陷与多动症状的演变 ADHD 实际上存在两项发育迟缓的心理特质。巴克利博士指出，首先出现的缺陷并非该病命名的“注意力”，从这个角度来说，ADHD 这个名字本身就存在误导。最早显现的核心缺陷其实是“行为抑制力”（Inhibition）的发育失败。这种抑制力的缺乏通常在学龄前便已显露： - **早期外显表现**：通常首发表现为多动（Hyperactivity）。个体的行为反应过多，无法像正常同龄孩子那样抑制无关行为。这不仅体现在运动行为上（过量的肢体动作、具有侵入性和破坏性的行为），也体现在语言输出上（话过多、插话）。 - **认知冲动性**：伴随着运动冲动的是闪电般的草率决策（Cognitive Impulsiveness），想到什么就立刻做什么，缺乏应有的延迟与审慎考量，完全不顾及后果。 - **活动水平的转变**：除了粗大运动的多动，还表现为“坐立不安”（Seat Restlessness）。巴克利博士认为，这种坐立不安对学业表现的负面影响远大于大范围跑跳的粗大动作。 - **年龄相关的退化**：随着年龄增长，外显的多动会急剧下降，到青春期几乎消失。到了成年期，多动完全内化为一种内部状态——一种内心深处必须忙碌、同时做多件事的冲动，以及思维与想法上的忙乱不安。 - **诊断效力丧失**：巴克利博士的研究表明，成年期的外显多动对于临床诊断已无任何价值；到 30 岁时，坐立不安往往更多与焦虑障碍挂钩，而不是 ADHD。 因此，ADHD 真正的根源不是外在的多动，而是抑制功能的发育失败，它全面侵蚀了个体的行为、语言以及内心的思维过程。 ### [07:26](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=446s) 情绪冲动性：被 DSM 遗忘的核心特征及其回归 巴克利博士指出，抑制力缺陷不仅波及行为和认知，同样严重影响情绪。但在当下的诊断体系中，情绪维度被不当地剥离了。 从医学文献的历史来看，ADHD 的记录并非始于大众熟知的 1902 年，而是始于 1798 年。大约在演讲的八年前，肯特州立大学（Kent State University）发现了苏格兰医生亚历山大·克赖顿（Alexander Crichton，当时居住于殖民时期的美洲）撰写的现存绝版医学教科书，其中有一章专门命名为“注意力疾病”（Diseases of Attention），对该障碍做出了极早且出色的描述。从 1798 年一直到 1976 年，包括马克·斯图尔特（Mark Stewart）的先驱研究，以及 1960 至 1970 年代加拿大学者韦斯（Weiss）、赫克特曼（Hechtman）、韦里（Werry）、道格拉斯（Douglas）等人的科学论文在内，长达 170 多年的历史中，所有的主流理论家和科研论文都无一例外地将“情绪冲动性”（Emotional Impulsiveness）视为 ADHD 的核心构成部分。 遗憾的是，精神疾病诊断与统计手册（DSM）后来将情绪剥离了出去，降格为少数患者身上偶然伴随的次要问题。巴克利博士对此进行了尖锐的批判：“It is as much a core feature of this disorder as is any other symptom in the DSM. And that was our mistake. And it needs to be returned to our understanding of ADHD.”（它与 DSM 中的任何其他症状一样，都是这一障碍的核心特征。将其剥离是我们的错误，必须将它重新纳入我们对 ADHD 的认知中。） 巴克利博士进一步解析了情绪冲动性的医学本质： - **具体表现**：易激惹、容易暴怒、极度易兴奋、挫折耐受度低下，以及情绪表达过于迅猛直接。 - **与心境障碍（Mood Disorders）的区别**：ADHD 的情绪问题不是心境障碍（如抑郁症或双相障碍）。心境障碍的本质在于个体产生了过量、异常的情绪；而 ADHD 是无法调节正常的生理情绪反应。 - **自我调节障碍的本质**：ADHD 患者产生的情绪本身是完全合情合理的，不正常的是他们缺乏缓冲与调节机制。他们无法实现自我安抚（Self-soothe）和自我冷静（Self-calm），无法为了适应环境、完成当前目标或保护自身长远福祉而适度弱化情绪反应，从而导致情绪失控并付出惨痛的社交代价。 - **与行为冲动的不可分割性**：情绪与人的每一句言语、每一个动作都紧密焊死在一起，它为人类行为染上色彩。行为上冲动的人，情绪上必然同样冲动，二者是一个不可分割的统一体。 重新确立情绪调节障碍的地位，不仅符合长期的医学历史，更能彻底解释许多临床困惑。巴克利博士指出，ADHD 患儿在确诊后短短两年内，罹患对立违抗性障碍（ODD，Oppositional Defiant Disorder）的概率比普通儿童高出整整 11 倍。目前的医学界仅将二者当作原因不明的共病（Comorbidity）敷衍了事，但一旦将情绪冲动性放回 ADHD 的核心定义之中，就会发现通往 ODD 的病理链条变得极其清晰自然。 ### [11:38](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=698s) 情绪调节与 ADHD：对立违抗障碍（ODD）与同伴排斥的根源 Russell Barkley 博士解释道，患有注意力缺陷多动障碍（ADHD）的儿童往往一开始就自动处于对立违抗障碍（ODD）的亚临床状态，只要再多出一个症状，就会跨过诊断门槛。换句话说，ADHD 本身就是导致 ODD 的元凶。ODD 虽然受到部分社会环境因素的影响，但其核心症状中有一半在于“无法管理沮丧、急躁与愤怒”。正是这种无法调控情绪的缺陷，引发了 ODD 的第二类成分——人际冲突、抗拒与争吵。Barkley 博士强调，ODD 的 8 项诊断标准中，前 4 项（愤怒、发脾气、敌意、易怒与烦躁）完全是情绪层面的问题，而这本就是 ADHD 的一部分。因此，无论是即将发布的 DSM-5 还是患儿家庭，都必须明白情绪问题与 ADHD 密不可分，绝非纯粹的外部共病。这也解释了为什么在使用药物治疗 ADHD 时，ODD 症状通常能获得几乎同等程度的缓解；未能缓解的部分则属于后天习得的“社会互动冲突”，需要通过行为干预去“去除习得”（unlearn）。 情绪失控的代价是极其惨痛的。Barkley 博士指出，50% 至 70% 的 ADHD 儿童在读小学二年级时，就已经被身边建立亲密友谊的社交圈彻底排斥。这是该障碍最具毁灭性的后果之一：无法与其他孩子建立并维持持久的亲密友谊。父母眼睁睁看着自己的孩子不如其他孩子受同龄人欢迎，被隔绝在过夜聚会（sleepovers）、一起看电影等同伴庆祝友谊的活动之外，内心无比心碎。导致同伴排斥的最强单一预测指标正是“情绪冲动性”。Barkley 博士犀利地分析了人际关系的本质：“朋友会原谅你的注意力涣散、健忘、工作记忆差甚至坐立不安，但他们绝不会原谅你的愤怒、敌意以及过快地向他人发泄情绪，因为这具有攻击性，在社交上代价惨重。” 这种情绪抑制缺陷不仅存在于童年，更贯穿整个人生历程。它直接解释了成年后的路怒症（road rage）、职场中因动辄发怒或对客户发飙而遭到解雇，以及严重的婚姻和育儿困境。Barkley 博士特别强调：“成年 ADHD 患者婚姻问题的最强单一预测指标并不是注意力涣散，而是情绪。”随后他幽默地自嘲道，光是讲完第一张幻灯片就花了 15 分钟，而他整整准备了 85 张，但他绝不会因此在讲座中敷衍家长。Barkley 博士郑重承诺，他会把在场的家长当成同行、学生和学者一样平等对待，绝不把知识“降智弱化”（dumb down），而会直接使用严谨的科学术语展开深入剖析。 - 50% 至 70% 的 ADHD 儿童在小学二年级前就遭受密友圈的彻底排斥。 - 药物治疗 ADHD 时，ODD 症状往往同步大幅减轻；残留的对抗多为后天习得的互动模式冲突。 - 成人 ADHD 的工作被解雇与婚姻破裂，其核心诱因是情绪失控而非注意力不集中。 --- ### [16:19](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=979s) 重新定义“注意力缺失”：目标持久性与对干扰的抑制失败 讲座进入第二维度——通常在第一维度（抑制问题）出现 2 至 3 年后滞后发育的特征，即所谓“注意力缺失”（attention deficit）。Barkley 博士直言这是一个巨大的用词不当（misnomer）。人类大脑中至少有 6 到 7 种不同形式的注意力及其支持网络，而 ADHD 并没有破坏所有网络。焦虑症、自闭症、抑郁症等几乎所有精神疾病都会在某些时刻干扰注意力，因此如果一个家长或患者仅仅抱怨“注意力不集中”，在诊断上是完全没有临床鉴别价值的。过去十年的研究表明，ADHD 的注意力缺失与其他疾病有着本质区别，其最准确的定义是“持久性的失败”（a failure of persistence）。 ADHD 并非大脑后部主管的知觉、信息过滤或加工过程出了问题，而是大脑额叶运动区域的缺陷。正如 Barkley 博士所阐述：“ADHD 是一种无法将行为在时间维度上向前引导的失败（ADHD is a failure to direct behavior forward in time）。”它意味着个体无法朝着生活中延迟的目标、任务和必须完成的终点持续行动，这深层关涉到行为、动机和未来指向性。为了向目标坚持，人必须抵抗沿途的干扰，但这同样不是知觉灵敏度的问题——ADHD 患者并没有比常人更灵敏地“感知”到干扰源，而是他们比常人更忍不住去“回应”干扰源。 Barkley 博士举了一个生动的现场例子：如果此时厨房传来洗碗的碰撞声，在场所有人其实都听到了，但大家都知道这与当前讲座无关并能选择忽略；然而 ADHD 个体却会产生一种无法抑制的行动冲动，甚至脱口而出：“听到那个了吗？他们在洗碗呢。我大学时就是靠洗碗打工赚学费的……”他们无法抑制这一反应，思维与行为随即被带跑，从一件未完成的事情跳向另一件事。 ```mermaid flowchart TD accTitle: ADHD注意力与执行功能缺陷机制 accDescr: 展示环境干扰如何通过抑制失败破坏目标坚持与工作记忆 subgraph Perception ["知觉输入（正常运作）"] Sensory["感知外界干扰<br/>（如厨房洗碗声）"] end subgraph ExecutiveBreakdown ["额叶执行功能缺陷"] InhibitionFail["运动抑制失败<br/>（强迫性做出行为反应）"] WMFail["工作记忆中断<br/>（遗忘原本行动目标）"] end subgraph ActionFailure ["行为表现"] GoalLoss["放弃未完成目标"] TaskHopping["在未完成的任务间频繁跳跃"] end Sensory --> InhibitionFail InhibitionFail --> WMFail WMFail --> GoalLoss GoalLoss --> TaskHopping ``` --- ### [19:24](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=1164s) 工作记忆断层与本质真相：从 ADHD 到自我调节发育障碍 除了无法坚持目标和无法抑制对干扰的反应，ADHD 还有第三个受损的关键环节，而它根本不属于注意力范畴——那就是“工作记忆”（working memory）。常人被意外打断后，往往能够重新回到未完成的目标上；ADHD 患者却很难做到这一点。Barkley 博士指出，工作记忆是人脑五大核心执行功能之一，这也证明了 ADHD 的实质是“执行功能缺陷障碍”（EFD, Executive Function Deficit Disorder）。工作记忆就是“为了行动而进行的记忆”（remembering so as to do），它负责在脑海中有意识、费力地维系“自己在做什么”以及“何时去做”。 Barkley 博士开玩笑地说，这就是上了年纪或步入更年期时会衰退的东西——人们丢掉的不是远期记忆，而是工作记忆，即突然忘了自己要去哪、手头正做什么、目标及其达成步骤。工作记忆一旦断线，脑海中的目标就会瞬间消失，而周遭任何具有刺激性的事物就会立即趁虚而入、捕获个体的行为，最终形成“在未完成的活动之间频繁跳跃”的典型症状。这三者——朝向未来的持久性匮乏、抵抗干扰的抑制力不足、以及丢失目标的工作记忆缺陷——共同构成了 ADHD 独特的额叶执行机制障碍，与焦虑症或学习障碍引起的走神有着天壤之别。 在剖析完这一机制后，Barkley 博士深刻反思了公众对该疾病的污名化与轻视。社会大众之所以无法像重视自闭症或精神分裂症那样重视 ADHD，很大程度上是因为这个名字本身显得微不足道。媒体和大众常常调侃：“注意力不集中？去星巴克喝杯咖啡提提神不就得了，精神病学界有比‘付不起注意力’更严肃的疾病要处理！”Barkley 博士指出，我们给这个疾病起错了名字。ADHD 在本质与灵魂上根本不是注意力问题，而是一种自我调节障碍： > “这是一种自我调节发育障碍，而不是注意力障碍；它是一种严重的障碍，严重程度不亚于躁郁症，在某些方面甚至不亚于自闭症。” 如果大家始终把它叫作 ADHD，就永远无法体会其病理的沉重性。Barkley 博士呼吁，应当将其更名为“自我调节发育障碍”（SRDD, Self-Regulatory Developmental Disorder），这样才能真正让全社会和患儿家庭理解这一疾病的严重性与残酷现实。 - ADHD 的实质应被称为 EFD（执行功能缺陷障碍）或更贴切的 SRDD（自我调节发育障碍）。 - 工作记忆的坍塌导致大脑无法留存目标，是患者频繁“半途而废、转做他事”的神经生物学根源。 - 现有名称 ADHD 极具误导性与轻浮感，导致其长期遭受媒体戏谑和公众的低估。 ### [23:12](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=1392s) ADHD 的本质：执行功能与自我调节障碍 Russell Barkley 博士指出，多动症（ADHD）绝不仅仅是注意力不集中。如果只是单纯的注意力问题，就无法合理解释为什么患儿几乎在所有需要日常运作的领域都会遭遇功能受损。ADHD 的深层本质在于执行功能障碍（Executive Function Disorder）以及自我调节障碍（Self-Regulatory Disorder）。人类进化出了一些极其独特的能力，但在 ADHD 患者身上，这些能力未能如期发育。Barkley 博士强调，父母必须看清这一点才能理解全貌：“If it's just an attention problem, why am I seeing impairments in virtually every domain in which this child is asked to function? That would not come from just inattentiveness, but it would come from an executive function disorder, a self-regulatory disorder.”（如果这只是注意力问题，为什么我在这个孩子被要求发挥作用的几乎每一个领域都看到了功能受损？这不可能仅仅来自注意力不集中，而是来自执行功能障碍，自我调节障碍。） 所谓的自我调节，首先是有意识、有意志地选择抑制（Inhibit）当下冲动行为的能力；其次是启动一系列“指向自我”的行动。自控的本质就是“对自己施加影响”，这些动作不再是对外部世界做出的反应，而是回过头来改变自身，从而让自己的行为从根本上偏离原有的即时轨迹。自我调节绝非仅仅服务于短期的自我改善，它的核心目的是为了个人的长远福祉（Long-term Welfare）。在采取行动前，个体必须能够停下来思考行为在未来可能带来的延迟性后果（Delayed Consequences）。ADHD 患儿所极度挣扎的，正是他们无法停下来、无法向内思考，导致其行为完全无法与未来的长远福祉对齐，因而远远落后于同龄人的发育进度。 ```mermaid flowchart TD accTitle: 自我调节的核心机制 accDescr: 展现从外界刺激到自我调节、再到行为改变与长远目标的思维机制流程 A["外界刺激/事件"] --> B{"能否按下暂停键？"} B -- "ADHD: 无法暂停" --> C["即刻冲动反应<br/>（仅关注眼前，无视未来后果）"] B -- "正常发育: 成功抑制" --> D["指向自我的内在行动<br/>（思考、心象、自言自语）"] D --> E["权衡延迟后果与长远福祉"] E --> F["调整与调节当前行为<br/>（改变长远未来）"] ``` --- ### [25:52](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=1552s) 自控力不是习得的：神经遗传学视角的颠覆性洞见 Barkley 博士向家长们揭示了一个打破绝大多数公众认知的科学事实：自我控制力根本不是后天“学”来的，它不是家庭教养（Upbringing）的结果，也不取决于父母有多么优秀。大量的 ADHD 研究得出了一个极具颠覆性的哲学结论——ADHD 在很大程度上是一种神经遗传性疾病（Neurogenetic Disorder）。既然 ADHD 是一种神经遗传性疾病，而 ADHD 本质上又是自我调节障碍，那么显而易见的逻辑推论就是：人类的自控力在源头上主要由神经遗传决定。 Barkley 博士掷地有声地总结道：“The vast majority of variation in the people sitting in this room and their ability to manage their behavior is not from how they were raised. It is a part of who they are. It is a part of their neurogenetic gifts.”（在座各位管理自己行为能力的大多数个体差异，并非来自后天的抚养方式。那是他们自身的一部分，是他们神经遗传天赋的一部分。）调节自我的能力是一种神经生物学特质，而非某种从父母那里耳濡目染捡来的社会化习得现象。虽然社会环境和训练能够让这种能力变得更熟练，但它们并不是能力的源头。就像语言能力一样，无论在何种文化环境中长大，人类都会发展出语言，后天教育只是提升其熟练程度；自控力同样是一种伴随大脑发育自然展现的本能。 - 自控力的本质：源于大脑神经生物发育的生物本能，而非单纯的家教产物。 - 后天训练的作用：只能塑造和优化（Shape and Enhance）已存在的神经基础，无法从无到有创造该功能。 - 缺陷根源：ADHD 患儿无法将行为指向自身，源于大脑发育中 5 项核心执行功能的落后。 --- ### [28:12](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=1692s) 前三大执行功能：抑制力、“心眼”（回顾与预见）与“心声”（内部言语） Barkley 博士将复杂的自控力拆解为个体“对自己做的 5 件事”，并系统阐述了前三项： 1. **抑制与等待（Stop & Wait）**：拉伯雷（Rabelais）在小说《巨人传》（*Gargantua*）中写过一句名言：“好事属于会等待的人”（Everything comes to those who can wait）。自控的第一步是在外部事件与你计划采取的行动之间构筑一个“暂停键”。而在 ADHD 患者身上，这个暂停机制是缺失的；刺激一旦出现，反应便脱口而出、随之而行。这就像神经系统退化为仅有脊髓反射的低等生物，Barkley 博士幽默地引用了 Gary Larson 在报纸连环画《The Far Side》中的经典漫画：两只变形虫（阿米巴原虫）夫妻在对话，妻子对着丈夫怒斥：“刺激、反应，刺激、反应。难道你就不会思考吗？”关于这种状态，Barkley 博士指出：“It is as if there was no front part to the brain. It is as if you were like any other species with a spinal cord. Event, response, event, response.”（就好像大脑前部根本不存在一样。就好像你成了某种只有脊髓的低等物种。事件，反应；事件，反应。） 2. **心眼与视觉想象（The Mind's Eye / Visual Imagery）**：一旦个体能够暂停，大脑就会调用心智剧场，在脑海中像播放 DVD 一样回顾过去的画面。常人依靠“后见之明”（Hindsight）提取过去的经验来指导当下，并将其转化为“先见之明”（Foresight）来预期未来。由于 ADHD 患儿无法停下来提取视觉记忆，他们既缺乏对过去的审视，也丧失了对未来的预见；他们无法使用过去的经验图像指引行动，只会鲁莽行事。 3. **心声与内部言语（The Mind's Voice / Internalized Speech）**：通常到 5 岁左右，儿童开始将外部语言内化为对自己说的话。如果观察 3 到 5 岁的孩子，会发现他们无论身旁是否有人都在自言自语（尤其在睡前）。在接下来的十年中，这种外在自语逐渐内化为无声的私密思维，即“脑海中的声音”。这道心声的存在只有一个关键使命：控制自己。通过脑海中的自我对话，指令才开始发挥效力。ADHD 患儿的这道声音极度微弱甚至缺失，这解释了为何他们无法内化场景规则，听不进指令，也无法遵守长效指引。 --- ### [32:03](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=1923s) 第四大执行功能：“心灵”与自我激励（为何能打几小时游戏却写不了作业） 在抑制力、心眼和心声的基础上，人类发展出了第四大执行功能——“心之感受”（The Mind's Heart），即调控自身情绪以契合社交要求和长远目标的能力。ADHD 患儿通常容易受挫、极易发怒、缺乏耐心、过度兴奋。但 Barkley 博士强调，更致命且常被忽视的底层真相是：**人类的情绪就是动机的来源**。无法管理情绪，就意味着无法管理动机；第四大执行功能正是“自我激励”（Self-Motivation）的源泉。 自我激励是所有指向未来的行为的“燃料箱”。没有自我激励，人就根本无法为明天做准备。失去了自我激励能力的 ADHD 患者，其努力程度和持续工作的能力将完全被动地依赖于周围环境所能提供的即时后果。Barkley 博士以此清晰解释了所有家长的经典困惑：为什么孩子可以连续几个小时沉浸在电子游戏中，却连几分钟作业都写不下去？这是因为电子游戏提供了外部的、持续的、100% 毫无延迟的即刻反馈与后果，而当孩子在白纸上解出一道算术题时，周围环境却没有任何即时反应，所有的奖励都是延迟的。Barkley 博士断言：“The work will not get done because the person cannot self-motivate. And this is not a choice, and this is not willful, and this is not a child who just could, if they wished, wake up tomorrow and smell the coffee and get busy and do the work.”（作业就是完成不了，因为这个人无法自我激励。这不是一种选择，不是故意的，也不是一个只要自己愿意就能明天突然清醒过来、忙活起来把事情做好的孩子。）如果将 ADHD 患者置于一个缺乏即时后果的环境中，其注定会失败；这是神经遗传导致的执行功能瘫痪，使患儿无论设立多么美好的目标，都缺乏内在燃料去实现它。最后，Barkley 博士引出了将在童年晚期才发育出的第五大执行功能（即心智的重新组合与分析能力）。 ### [34:52](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=2092s) 核心执行功能：规划、问题解决与五大能力的延迟 执行功能的最高境界在于在心智中进行多重未来可能性的模拟。面对突发阻碍，一个人能在脑海中以多快的速度生成多种替代方案去绕过难题，这构成了人类所有文化创新的源泉，而其底层逻辑正是问题解决与规划能力。然而，ADHD 患者在这一维度上的受挫程度与其它维度无异。 家长若想真正理解 ADHD，必须明白患儿在五种基本执行能力上均存在显著延迟：第一是抑制与停顿的能力；第二是运用视觉心像的能力；第三是运用内心声音的能力；第四是调动内心感受、情绪与动机的能力；第五则是面对问题或构想目标时，在脑海中模拟多种方案以进行规划和问题解决的能力。这些功能定位于大脑额叶，科学界清楚知道 ADHD 患儿并非彻底丧失了它们，而是发展严重滞后。 ```mermaid flowchart TD accTitle: ADHD患儿受损的五大核心执行功能 accDescr: 展示人类额叶所支撑的五大核心执行功能，ADHD患儿在这些能力上均存在发育延迟。 subgraph EF["五大核心执行功能（额叶调控）"] A["1. 行为抑制<br/>（自主停顿的能力）"] B["2. 视觉心像<br/>（运用事后之明与先见之明）"] C["3. 内心声音<br/>（私密言语、自我提醒与讲理）"] D["4. 情绪与动机<br/>（自主安抚与内在驱动力）"] E["5. 模拟与规划<br/>（多方案推演、解决问题）"] end A --> B A --> C A --> D A --> E ``` 执行能力的全面延迟导致 ADHD 患儿无法抵抗分心、行事冲动，他们既无法回顾过往经验，也无法预见未来后果。由于无法通过“向后看”来“向前看”，患者彻底失去了主观时间感，沦为“活在当下”的俘虏，进而导致严重的成人期时间管理残疾。此外，患儿缺乏与自己对话、自我讲理、自问自答以及调取情境规则的能力，这意味着来自外界的唠叨完全无济于事。 > “No amount of nattering by your teacher or your mother will overcome the internal mind's voice deficit.” —— Russell Barkley - DSM 手册中列出的行为症状只是这五大深层执行功能缺陷的表层投影。 - 将 ADHD 仅仅称为“注意力缺失”，就如同将自闭症轻描淡写地概括为“挥手和说话怪异”一样，掩盖了疾病深层的核心本质（自闭症的本质是无法将他人视为特殊的人类客体建立联结）。 --- ### [38:33](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=2313s) 摒弃 DSM 亚型：ADHD 伴发品行障碍的恶性亚群 精神疾病诊断与统计手册（DSM）中所划分的“注意缺陷型”、“多动型”和“混合型”三种亚型在临床现实中并不成立。人类群体中只存在一种单一的 ADHD，各个亚型所捕捉到的仅仅是该疾病在严重程度上的差异。相比于 DSM 毫无用处的分类方式，欧洲临床界沿用了数十年的方案更具指导价值：即根据“是否伴有品行障碍（Conduct Disorder, CD）”来进行亚群划分。 在北美，品行障碍过去长期仅被视为一种共病，但证据表明，同时患有 ADHD 和品行障碍的儿童表现出一种极其独特的严重病症。这类儿童发病更早、症状更重、病程更具持续性，不仅预示着成年后持续的反社会行为，更携带了极高的精神病态（Psychopathy）风险。 > “One in five of these children is a budding psychopath. A child who lacks guilt, conscience, empathy, and remorse. A child who is a predator.” —— Russell Barkley - ADHD 本身并不导致精神病态，但“ADHD 伴发品行障碍”是目前已知预测精神病态最强有力的单一指标。 - 品行障碍的核心定义是出于自身利益而去侵犯他人权利，在童年早期典型表现为说谎、偷窃、打架，以及工具性地掠食、欺凌其他儿童。 - 当 ADHD 与品行障碍交织在一起时，便构成了一种极具破坏力与侵略性的烈性障碍。 --- ### [40:59](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=2459s) 所谓亚型的临床真相与 SCT（迟缓认知节奏）的本质辨析 单纯的“多动型”在临床上几乎是一个伪命题：该群体中 90% 的儿童会在 3 年内发展为混合型，另有约 5% 仅仅是差一个症状未达到混合型阈值，这两者合占了该群体的 95%。剩余的 5% 则是单纯的对立违抗障碍（ODD），通常在 2 到 4 年内自愈，其被误诊是因为家长容易将违抗行为与 ADHD 混淆。 在“注意缺陷型”群体中，超过半数原本就是混合型，只是随着青春期和成年期的到来，多动症状逐渐减弱，导致临床医生错误地将其重命名为注意缺陷型。更关键的发现出现在剩下的人群中：当前被归为注意缺陷型的患儿里，有 30% 到 50% 实际上患有一种完全不同的疾病——迟缓认知节奏（Sluggish Cognitive Tempo, 简称 SCT）。 | 维度 | 注意缺陷多动障碍 (ADHD) | 迟缓认知节奏 (SCT) | |:--- |:--- |:--- | | **核心缺陷** | 抑制力受损、自我调节障碍、执行功能全面迟缓 | 信息加工速度障碍、焦点注意力选择障碍 | | **注意力特征** | 无法保持注意力的持久性（Persistence） | 无法在众多信息中筛选重要与非重要内容 | | **记忆表现** | 工作记忆受损，无法有效保留当下信息 | 长时记忆存储障碍或记忆检索困难 | | **社交表征** | 冲动、外向、边界感弱、易与人冲突 | 社交退缩、沉默寡言、害羞、多疑、社交焦虑 | | **伴发问题** | 高频伴发对立违抗（ODD）与品行障碍（CD） | 极低伴发 ODD 和 CD；伴有极高比例的焦虑障碍 | SCT 儿童之所以被硬塞进 ADHD 的分类标签中，纯粹是因为 DSM 体系内缺乏其他注意力维度的诊断类别。SCT 患者不仅没有任何抑制障碍，也不具备 ADHD 特有的自我调节缺陷和五大执行功能障碍。两者在抑郁发生率上相当（约 20% 至 25%），但 SCT 儿童表现出的退缩、胆怯与信息加工迟滞，证明其绝非 ADHD 的一种亚型，而是一种质性完全独立的病理实体。 ### [45:14](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=2714s) SCT 与 ADHD 的本质差异：家庭忧虑、学业表现与家族背景 在对比迟缓认知节奏（SCT）与注意缺陷多动障碍（ADHD）时，Barkley 博士指出，两类儿童的家庭所承受的心理压力截然不同。SCT 儿童本质上是“好孩子”，他们在校外并不具备破坏性，甚至能交到几个朋友；虽然朋友数量不及普通儿童，但已经明显多于 ADHD 儿童所能维持的社交圈。因此，SCT 家长唯一的焦虑核心就是学校表现与作业错误：“SCT families don't worry about any of that stuff. ADHD families worry, and well they should.”（“SCT 家庭根本不担心那些事情；ADHD 家庭却忧心忡忡，而他们确实理应担忧。”）ADHD 患儿的家长每天都在为所有事情提心吊胆：同伴关系、家庭功能、社区行为，更不用提随着孩子步入青春期，面临驾驶、就业、金钱管理以及性活跃等接踵而至的现实风险。 从学业完成情况来看，两者的表现构成了根本的质性分歧。SCT 患儿能把所有的功课写完，但交上去却有一半是错的；相反，ADHD 患儿则是一点作业都不做。基于此，Barkley 博士给出了一个高度概括的核心论断：“SCT is an accuracy disorder, ADHD is a productivity disorder.”（“SCT 是一种准确性障碍，而 ADHD 是一种生产力障碍。”）此外，SCT 儿童可能更容易出现数学障碍（尽管目前尚无定论）。 从家族遗传背景分析，两者的发病谱系也大相径庭。SCT 儿童往往来自具有类似特质的家庭，主要表现为较高的焦虑倾向和较多的校内学习困难；而 ADHD 儿童的家族史则要沉重得多，充斥着大量的 ADHD 病史、学业挫败、反社会行为、酗酒、抑郁症以及药物滥用。 ```mermaid flowchart TD accTitle: Comparison between SCT and ADHD accDescr: A structural comparison between Sluggish Cognitive Tempo and ADHD across impairment type, core problem, and family history. subgraph SCT["迟缓认知节奏 (SCT)"] A1["核心性质：准确性障碍<br/>(Accuracy Disorder)"] A2["学业表现：作业全写完，但错一半"] A3["家族背景：焦虑高发、学校学习障碍"] A4["主要担忧：仅局限在学校学业"] end subgraph ADHD["注意缺陷多动障碍 (ADHD)"] B1["核心性质：生产力障碍<br/>(Productivity Disorder)"] B2["学业表现：完全不写作业"] B3["家族背景：反社会行为、酗酒、抑郁、药物滥用"] B4["主要担忧：涵盖学业、同伴、家庭、驾驶、性安全等全方位"] end ``` --- ### [46:51](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=2811s) 干预措施的分歧：药物有效性、社交技能训练与偏常训练风险 由于 SCT 与 ADHD 的底层机制不同，常规干预手段在两者身上的效果呈现出巨大反差。治疗 ADHD 的常规一线药物在 SCT 儿童身上表现并不理想：药物虽然不会伤害他们，低剂量相对最适宜，但总体帮助极小。Barkley 博士指出，在其开展的研究中，临床试验结束后仅有五分之一（20%）的 SCT 儿童会继续维持药物治疗，而 ADHD 儿童的用药依从与留存率高达 92%。 相反，SCT 儿童对社交技能训练（Social Skills Training）的反应非常出色。这一疗法早在 40 年前就是为了害羞人群设计的，其本质更契合害羞群体而非攻击性群体。然而，ADHD 儿童在传统社交技能训练中几乎毫无起色。Barkley 博士严厉批评了脱离实际生活情境的训练营模式，强调如果要在 ADHD 身上取得效果，训练必须由教师在学校日常环境中进行，并配合及时的现场提示与奖励，而不是把孩子送进夏令营或周六上午的门诊诊所：“If you're doing that, you're probably wasting your money.”（“如果你正在做那种事，你可能只是在浪费钱。”） 更具警示意义的是，临床干预可能带来意想不到的负面效果。研究表明，被放入社交技能小组的儿童中，有四分之一（25%）的病情反而会恶化。这种现象在心理学上被称为“偏常训练”（Deviancy Training）——组内具有较强攻击性的儿童会“训练”攻击性较弱的儿童变得更具侵略性，即便初衷仅仅是为了自卫。因此，ADHD 儿童有 25% 的概率会因社交技能训练而变得更糟。另外，MTA（Multimodal Treatment of ADHD）多模态研究发现，焦虑感是行为干预反应的最强预测因子；由于 SCT 儿童普遍更为焦虑，他们对行为矫正治疗的响应度可能甚至优于 ADHD 儿童。 - **认知疗法（CBT）的局限**：认知训练要求儿童进行“自我对话”（内省语言）。ADHD 儿童由于“心智之声”（Mind's Voice）的发育滞后，童年期 CBT 彻底失效，直到成年期内化语言发展成熟后才可作为药物治疗的补充手段；而 SCT 是否能从儿童期认知疗法中获益，目前仍是学术空白。 - **潜在药物推测**：Barkley 博士推测，择思达（Strattera / 阿托莫西汀，Atomoxetine）因其兼具抗焦虑特性，可能对 SCT 有效；而用于治疗发作性睡病的莫达非尼（Provigil / Modafinil）因其脑干刺激机制，可能更针对 SCT 的嗜睡、行动迟缓、发呆和注意力散漫等类似睡病的症状。 - **对家长的警告**：千万不要让 SCT 孩子的家长去读 ADHD 相关的书籍，否则会得到完全错误的预后风险和无效的治疗指导。加州大学旧金山分校（UCSF）约一年前才发表了首批针对 SCT 的心理治疗研究，该领域仍处于探索起步阶段。 --- ### [51:58](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=3118s) 执行功能缺陷的根源：纯粹的生物学归因与社会环境的三大影响 谈到核心原则之六时，Barkley 博士打趣说总共有 25 条原则要讲，现在才刚到第 6 点，随后迅速开启了关于 ADHD 病因学的“三分钟速成课”。他首先斩钉截铁地明确了病因的界限：ADHD 是多重因素共同作用的结果，但所有根源全部属于生物学领域。现存医学证据表明，没有任何一种社会影响或后天教养方式能把一个正常儿童变成 ADHD 患儿；如果有任何人声称科学界尚不知道 ADHD 是大脑哪个部位出问题，那纯属无稽之谈。 但这绝不意味着社会因素毫不相关。Barkley 博士特别声明，不要误解他的意思并传谣说“Russ 认为社会因素无关紧要”：“Kindly do not leave this room and say that Russ said that social factors don't matter. I didn't say that. I said they don't cause it.”（“请不要离开这个房间后就说‘Russ 说了社会因素不重要’；我没那么说，我说的是社会因素并非致病原因。”）他将社会环境的作用明确归纳为三大现实层面： 1. **可用治疗资源**：家庭能够调动并获得的治疗支持和医疗资源，高度取决于周遭的社会经济与支持环境。 2. **功能受损程度**：环境的架构方式直接决定了孩子的受损程度；家长与学校完全可以通过重新布局环境来显著减轻其障碍。 3. **共病（Comorbidity）的发生**：与 ADHD 经常伴随出现的对立违抗障碍（ODD）、品行障碍（CD）、焦虑症和抑郁症，其 40% 到 50% 的变异确实是由后天社会环境造成的。 --- ### [53:56](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=3236s) 后天获得性 ADHD：妊娠风险、后天损伤与链球菌免疫攻击 在病因分布上，大约有三分之一（约 33%）的 ADHD 属于非遗传性质的“后天获得性”（Acquired）病例，其中绝大部分是在妊娠期间由于大脑前额叶发育受阻造成的。此外，约有 5% 的病例发生在出生之后，通常由影响关键脑区发育的创伤、严重感染以及各类外界毒素所致；这类后天获得性患儿也是最容易并发癫痫发作（Seizures）的群体。 后天获得性诱因不仅包含常见的铅中毒，还包括儿童期白血病的治疗过程（如放化疗可能伤及神经系统）。另一个极具代表性的生物学诱因是链球菌（Strep Bacteria）感染。链球菌本身并不直接啃噬大脑，而是由于其外壳蛋白与人体脑部神经细胞表面的蛋白质分子结构完全一致；当机体免疫系统为了清除病菌而产生抗体时，抗体无法准确辨别细菌与神经细胞，进而引发自身免疫反应并攻击特定脑区。这种免疫失误一旦损伤了调控注意力和冲动控制的核心脑回路，就会诱发 ADHD。虽然这一病例在临床上并不普遍，但它清楚地揭示了生物学病理对神经发育障碍的直接决定作用。 ### [55:10](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=3310s) ADHD 的五个关键脑区与脑成像的诊断误区 罗素·巴克利博士（Dr. Russell Barkley）指出，医学界已经确切掌握了引发 ADHD 的大脑结构。在大约三分之二的患儿中，脑区体积偏小的主要原因源于遗传。这套相互连接并导致该障碍的脑网络主要由五个区域构成：首先是额叶右侧（尤其是眉毛正上方的区域）；其次是深入大脑内部并与额叶紧密相连的基底神经节（Basal Ganglia）；接着是连接大脑中央与后方较为原始的小脑（Cerebellum），该结构在患者脑中同样体积较小；第四个是位于双眼之间、两半球内侧壁深处的扣带回前部（Anterior Cingulate），这里正是情绪失调的根源所在；最后则是连接左右大脑半球的胼胝体（Corpus Callosum），由于前端大脑变小，胼胝体自然也相应缩小。 这整套神经网络的缩小程度与 ADHD 的严重程度直接挂钩。在遗传患病的儿童中，这些脑区大约比常人缩小 3% 到 10%。巴克利博士强调，这看似微小的缩水虽然足以引发障碍，但并不足以作为临床脑成像的诊断标准。微小的差异导致无法单靠扫描对个体进行归类，因此市面上任何脑成像技术都无法用于实际诊断。针对商业化的脑扫描宣传与外界对药物治疗的质疑，巴克利博士直言不讳地反驳道：“Which is why no brain imaging technique, including Dr. Amen's SPECT scanning, is of any value for diagnosis.” 此外，与演员汤姆·克鲁斯（Tom Cruise）及山达基教（Scientology）的言论相反，这些大脑结构差异完全是由障碍本身引起的，与儿童是否服用药物毫无关系。 - 涉及脑区：右侧额叶（特别是眼眶额叶区域）、基底神经节、小脑（尤其是右侧中央部分）、扣带回前部、胼胝体。 - 脑区缩减比例：仅为 3% 至 10%，足以造成机能障碍，但不足以通过 SPECT 等扫描技术诊断个体。 - 发育轨迹：大脑体积等结构性差异在 16 至 18 岁左右可能会趋于正常化，但大脑的实际运作功能并不会随之恢复正常。 ### [57:20](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=3440s) 大脑发育延迟与运动皮层的反向失衡 巴克利博士通过屏幕展示了右侧眶额区、扣带回前部、基底神经节和小脑的神经投影，并分享了加州大学洛杉矶分校（UCLA）的一项最新研究发现：ADHD 患儿的父母及亲兄弟姐妹的大脑中，上述神经网络同样偏小，但唯独小脑发育正常。这意味着大多数脑部差异属于家族表型（Family Phenotype），即使未发病的家庭成员也携带这种发育不足的模式；而真正促使 ADHD 完全显现的诱因，很可能是小脑也同时受到了影响。 涵盖蒙特利尔、纽约和华盛顿的多中心纵向神经发育成像研究追踪了 223 名正常儿童与 ADHD 儿童长达 10 年。这项开创性的研究证实，ADHD 儿童的额叶在体积生长上平均存在 2 到 3 年的滞后。与此同时，成像图上后方主管视觉意象（第二项执行功能）的区域也表现异常。最惊人的是大脑的运动皮质区（Motor Strip）不仅没有滞后，反而提前了 2 到 3 年发育。这种结构上的脱节形成了运动皮质疯狂输出行为、而负责刹车制动的额叶却发育滞后的失衡局面。正如巴克利博士总结道：“So, you've got a motor strip that's generating behavior and a frontal lobe that's not regulating it.” ```mermaid flowchart TD accTitle: ADHD大脑发育不均衡机制 accDescr: 展示运动皮质提前成熟与执行系统发育延迟导致的失衡 subgraph Delay ["成熟滞后 (发育晚 2-3 年)"] FL["额叶 (执行控制 / 行为刹车)"] AC["扣带回前部 (情绪调节)"] CB["小脑 (协调与定时)"] end subgraph Advance ["成熟提前 (发育早 2-3 年)"] MS["运动皮质区 (行为与动作冲动产生)"] end MS -->|"产生过量动作输出"| Behavior["多动与冲动行为"] FL -.->|"无法提供有效制动与调控"| Behavior ``` ### [01:00:00](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=3600s) 遗传机制与环境养育神话的破灭 巴克利博士明确指出，ADHD 是一种基于大脑发育延迟的疾病，且绝大多数源于遗传。大约三分之一的男性患者属于后天获得性（如脑外伤等原因导致），而在女性患者中后天获得的比例极低，绝大多数女孩都属于遗传型。家系调查显示，ADHD 具有极高的家族聚集性：患儿的亲兄弟姐妹有 25% 的患病风险；同卵双胞胎的共患率高达 78%；患儿的母亲中有五分之一自身患有成人 ADHD，父亲则接近三分之一；两相结合，意味着就诊家庭中父母双方有一方患病的概率高达 50%，且通常从未被确诊过。同时，患有 ADHD 的成年人，其子女有 40% 的概率患病。 双胞胎研究进一步证实，ADHD 的遗传度平均达到 80%，在部分研究中甚至高达 91%，其可遗传程度堪比人类的身高。与此形成残酷对比的是，大众普遍将多动症归咎于父母管教不力。巴克利博士以过去 20 年间发表的所有 40 项双胞胎研究结果打破了这一偏见：“All 40 twin studies published in the last 20 years have shown that the rearing environment has no influence on this trait.” 养育环境对 ADHD 核心特质的影响实际上为零，家庭抚养环境绝非致病原因。 - 遗传风险概率： - 兄弟姐妹共患风险：25% - 成人患者子女发病率：40% - 父母一方患病概率：高达 50%（母亲约 20%，父亲近 33%） - 同卵双胞胎共患率：78% - 遗传度指标：人群症状差异的 80% 到 91% 由基因差异决定，养育环境贡献为 0%。 - 临床要求：鉴于高遗传率，精神科与儿科医生必须常规筛查带孩子就诊的父母。 ### [01:02:22](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=3742s) 多巴胺调控基因与神经元突触传递 在分子遗传学层面，ADHD 是精神病学领域基因定位最成功的障碍。人类基因组扫描显示，与 ADHD 相关的基因位点大约有 20 到 25 个，目前科学家已经锁定了其中的 5 到 7 个关键位点。值得注意的是，前四个已确认基因的首字母均带有“D”，这代表它们直接负责调节大脑内部的多巴胺系统。既然关键风险基因掌管着多巴胺的运作，那么能够提升脑内多巴胺浓度的药物有效改善 ADHD 症状也就顺理成章。药物不是遮羞布，而是直接从生理底层改变这些基因对大脑功能的影响。巴克利博士由此阐明了药物治疗的根本属性：“Which means that psychopharmacology is a form of genetic treatment.” 巴克利博士以额叶神经元为例形象地解释了神经信号的传递过程：当神经元受到电刺激时，电脉冲沿轴突向下传导，神经末梢内储存多巴胺的囊泡会向细胞膜外缘移动并破裂，将多巴胺喷射到神经元之间的突触间隙中。多巴胺跨越间隙并与下一个神经元的受体膜结合，从而引爆下一个电脉冲。在突触前膜上，分布着许多被称为转运蛋白的结构，巴克利博士将其生动地比作“吸尘器”或微型水泵，它们的主要功能便是在多巴胺完成信号传递后迅速将其回收。 - 已知基因位点数量：全基因组扫描确认共有 20-25 个相关位点，目前已确切查明 5-7 个。 - 多巴胺相关性：已知的主要候选基因（如多巴胺受体及转运体相关基因）均以“D”开头，直接证明病理根源在于多巴胺通路故障。 - 药物作用性质：精神药理学并非“创口贴”或掩盖病情的权宜之计，而是一种直接调控基因表达缺陷的基因水平对症治疗手段。 ### [01:04:36](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=3876s) 基因、多巴胺转运蛋白与药物靶点的生物学联系 Dr. Russell Barkley 详细解释了神经细胞表面的“再摄取转运蛋白”（reuptake transporter，即多巴胺转运蛋白）。这个机制就像一个泵或吸尘器。名为 DAT1 的基因负责制造和运作这个多巴胺转运泵。如果一个人携带的是该基因的较长变异版本，其神经细胞表面就会装配过多的转运泵。结果是，一旦神经细胞放电释放多巴胺，这些神经递质瞬间就会被“吸尘器”吸回细胞内，根本来不及发挥应有的信号传导功能，使大脑处于多巴胺匮乏的状态。 研究表明，ADHD 患者基底神经节（basal ganglia）神经细胞上的多巴胺转运蛋白数量比常人多出 30% 到 80%。针对常用的 ADHD 治疗药物 Ritalin（利他林）或 Concerta（专注达），Dr. Barkley 打了一个非常形象的比方：它的药理机制就像拿一只袜子堵住了吸尘器的软管口。哌甲酯（methylphenidate）能够有效阻断这些转运蛋白的工作，从而把更多的多巴胺留在神经元突触间隙中。与之类似，Strattera（择思达/托莫西汀）也是通过抑制再摄取起效，主要针对去甲肾上腺素，并对多巴胺有轻微作用。 这项科学突破的意义在于，现代医学首次将“特定基因”、“大脑结构/神经生物学异常”以及“药物作用机制”清晰地串联了起来。过去已有三项研究证明，DAT1 基因能直接预测患者对哌甲酯的治疗反应。Dr. Barkley 预言，也许在未来大约五年左右，患者走进诊所时，医生只需采集一点唾液样本进行基因分型，就能精准决定该开哪种药，迈入“基因预测药物反应”的个性化医疗时代。 ```mermaid flowchart LR accTitle: 多巴胺转运蛋白与药物机制 accDescr: 展示DAT1基因如何导致转运蛋白增多并被哌甲酯阻断的生物学链路 subgraph GENE["基因层面"] G1["DAT1 较长变异基因"] end subgraph BRAIN["大脑神经元突触"] P1["神经元表面转运蛋白过多<br/>(增加 30%–80%)"] P2["多巴胺被过度回抽<br/>(细胞外多巴胺不足)"] end subgraph MED["药物干预"] M1["哌甲酯 (利他林 / 专注达)"] M2["阻断转运蛋白 (堵住吸尘器)"] M3["突触间隙多巴胺水平恢复"] end G1 --> P1 P1 --> P2 M1 --> M2 M2 -.->|"逆转缺陷"| P2 M2 --> M3 ``` - DAT1 基因编码控制多巴胺再摄取转运泵的合成与运作。 - ADHD 患者基底节区域的转运蛋白密度比正常基准高出 30% 至 80%。 - 哌甲酯（利他林、专注达）是多巴胺再摄取抑制剂；托莫西汀（择思达）主要是去甲肾上腺素再摄取抑制剂。 - “But nevertheless, we can now link a gene to a problem in the brain and we can link that problem to a drug.” —— Dr. Russell Barkley --- ### [01:06:16](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=3976s) 基因与环境毒素交互作用：ADHD 遗传学前沿 ADHD 的发病并不仅由单一基因决定，而是基因与环境因素复杂交互的结果。Dr. Barkley 引用了圣路易斯知名精神病遗传学家 Richard Todd（在发表该论文后不久不幸突然离世）的一项里程碑式研究。该研究对儿童进行了基因分型，检测他们是否携带 DAT 基因及另一种风险基因，并追踪了母亲在怀孕期间是否有吸烟史。 研究数据表明，当同时携带这两种风险基因且母亲在孕期吸烟时，孩子患 ADHD 的风险会飙升至常人的 8 倍，远高于单纯具备基因风险或单纯接触毒素的情况。这就是典型的“基因与毒素交互作用”（gene by toxin interaction）。近期在酒精暴露方面也发现了完全相同的交互规律。一些 ADHD 病例正是胚胎期接触外界毒素与内在遗传易感性共同作用的产物。 遗传学目前是整个 ADHD 研究中进展最迅猛的领域，每年有超过 100 篇高质量专题论文发表。Dr. Barkley 指出，基因检测未来不仅能辅助确诊和细分亚型，还能揭示其他共病风险。例如，调控多巴胺转运蛋白的 DAT 基因同样是尼古丁成瘾的高危预测因子。此外，最新研究发现，孩子对行为矫正（behavior modification）疗法的敏感度和反应程度，也在一定程度上受基因调控，未来医学界有望针对特定的基因亚型开发全新的靶向药物和心理社会干预方案。 - 携带双重风险基因叠加孕期母体吸烟，导致 ADHD 发病风险提升 8 倍。 - 孕期饮酒与易感基因之间同样证实存在显著的基因-毒素交互致病机制。 - 调控转运蛋白的 DAT 基因亦是尼古丁成瘾的预测标志物。 - 儿童对心理治疗与行为干预的敏感性部分由遗传基因介导。 - “Sensitivity to psychological treatment may be in part genetically mediated.” —— Dr. Russell Barkley --- ### [01:08:37](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=4117s) 破解伪科学迷思：电视、饮食与教养并非致病根源 谈到公众认知，Dr. Barkley 严肃地强调，家长必须明确认识到 ADHD 绝非由家庭环境或社会不良因素引起的。针对媒体和大批未受专业科普教育的家长中广为流传的各种归因假说，他逐一进行了严厉驳斥。首当其冲的就是“看电视和打电子游戏导致注意力缺陷”的论调，Dr. Barkley 甚至直言：“If I hear this again in the media, I'm going to throw up.” 科学事实表明，人类的注意力跨度根本没有缩短，真正改变的只是当今社会中可供人们消磨分心的媒体形式变得极度丰富。ADHD 患者确实看电视更久、玩电子游戏更多、上网更频繁、手机通话和发短信/推特也更密集，但这不是因果倒置的理由——不是媒体引发了 ADHD，而是 ADHD 患者由于大脑难以长时间维持枯燥阅读或单调专注，本能地选择这些节奏快、刺激强、极具吸引力的媒体作为消遣。 Dr. Barkley 同样澄清了饮食与育儿的误区： 1. **食品添加剂**：不会导致 ADHD。尽管大约每 20 个 ADHD 患儿中可能有 1 人的症状会因摄入添加剂而轻微加重，但这在科学上属于微不足道的微弱发现，家长完全不需要通过大动干戈改变食谱来试图“治愈”ADHD。 2. **Omega-3 / 鱼油补充剂**：瑞典一项严格的随机对照试验证明，鱼油对联合型 ADHD（ADHD combined type）基本无效，仅对少于 25% 的迟缓认知节奏/注意力涣散型（SCT / inattentive type）有极其微弱的边际改善。 3. **家庭抚养方式**：教养方式与 ADHD 的发病完全无关。 在 ADHD 的致病因素分布饼图中，遗传因素占据了大约 65%，其余则全是导致脑损伤的生物性危害（biohazards），“社会环境或教养失败”在致病因构成中占比为零。 - 没有任何科学证据表明现代人类的注意力跨度在缩短。 - 食品添加剂仅在极少数（约 5%）患儿身上表现出轻微的症状波动，非致病因。 - 瑞典随机对照试验证实鱼油（Omega-3）对联合型 ADHD 几乎无效。 - ADHD 病因构成中约 65% 为遗传，其余基本为生物物理/脑损伤危害，不含社会家庭成因。 - “There is no evidence that human attention spans have changed at all. What is changing is the amount of media you can distract yourself with if you so choose.” —— Dr. Russell Barkley --- ### [01:10:58](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=4258s) 核心障碍本质：时间盲与“对未来的近视” Dr. Barkley 强调，当我们将 ADHD 理解为一种神经生物学与自我调节障碍时，就会得出全场最关键的洞见：ADHD 的终极核心特征就是“永远活在当下”（It's always now）。如果用一句话来概括 ADHD，那就是“时间盲”（time blindness）。患者丧失了感知和驾驭时间维度的能力，无法通过“向后看”回顾经验来“向前看”预测并筹划未来，整个人永远被眼前的即时刺激牵着鼻子走。 为了生动说明这一点，Dr. Barkley 分享了他在马萨诸塞州成人门诊遇到的真实案例： 一位濒临崩溃的妻子带着丈夫前来就诊，妻子痛诉丈夫就像家里的第四个孩子，扬言再不解决就要离婚。事情起因于上个周末，丈夫推着割草机去院子里除草，发现割草机没油了；转头找备用油桶，油桶也是空的。于是他把油桶扔进福特探险者（Ford Explorer）车后备箱，开车去街角的便利店加油。在加油站，正巧碰上开着同款车的朋友。朋友随口一句：“今天是鳟鱼溪垂钓解禁首日，要不要去钓会儿鱼？”这位丈夫立刻跳上朋友的车飞钓去了。两人在溪边钓了 6 个小时，口渴后又转战小酒馆喝啤酒。与此同时，州警在加油站发现了他的车——发动机还在怠速运转，敞着口的油桶扔在一旁。直到下午 4 点，这位丈夫才施施然晃荡回家。 这个案例生动揭示了 ADHD 患者大脑的运作模式：无论原本的目标、计划与责任是什么，当下的刺激永远比大脑工作记忆中维持的未来信息更具压倒性的引力。 从演化神经科学的角度来看，人类大脑额叶的核心功能，就是“跨越时间组织个体行为，以应对即将到来的未来”。因此，ADHD 在本质上造成了对时间的盲目；更精准的神经学定义，是“对未来的近视”（a near-sightedness to the future）。正如近视眼患者只能看清眼前近距离的文字一样，ADHD 患者的思维与行为只能处理时间轴上近在咫尺的事物；一旦事件落在未来的时间轴远端，他们便完全无法调动行为去做出应对。 - 人类额叶的生物学目的：跨越时间组织行为以应对未来。 - ADHD 的本质是“时间盲”（time blindness）与“对未来的近视”（near-sightedness to the future）。 - 眼前即时的外部刺激（The Now）永远压倒脑中储存的目标与既定计划。 - “ADHD is, to summarize it in a single phrase, time blindness.” —— Dr. Russell Barkley - “ADHD, right? Is at its heart a blindness to time, or technically, to be exact, it is a near-sightedness to the future.” —— Dr. Russell Barkley ### [01:14:03](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=4443s) 时间感知受损与行为层级结构的崩溃 Dr. Russell Barkley 进一步剖析了 ADHD 儿童为何总把所有事情拖延到最后一刻：因为他们所能感知、应对并为之组织行为的全部范围，仅仅是“最后一分钟”。他们的生活因此沦为接二连三的危机串联，而这些危机原本只要提前做好准备便完全可以避免。常人能够在正确的时间、合宜的时间段内把所需的事物准备就绪，ADHD 患者却无法做到。正如 Barkley 强调：“ADHD is destroying the timing and timeliness of human behavior.”（ADHD 正在摧毁人类行为的时效性与准时性）。三岁的孩子或许不需要时间观念，但三十岁的成年人必须具备；成年期因 ADHD 导致的最具破坏性的缺陷之一，正是对时间织锦的撕裂。 ```mermaid flowchart TD accTitle: ADHD行为层级瓦解图 accDescr: 展示常人如何将微小行为组织成宏观目标，以及ADHD患者在层级组织上的断裂。 subgraph NormalHierarchy ["常人行为层级构建"] A["顶层宏观目标（如：筹备婚礼）"] --> B["中层决策树（预订教堂、联系司仪、租场地）"] B --> C["底层微小例行子程序（拿起电话拨号码）"] end subgraph ADHDDisruption ["ADHD 患者的行为碎片化"] D["微小行为断片（时断时续、零敲碎打）"] E["❌ 无法跨越时间黏合行为"] F["❌ 顶层目标瓦解 / 表现为注意力涣散"] D -.-> E -.-> F end ``` 这种跨越时间组织行为的能力，本质上是自下而上搭建“行为金字塔”的能力——从最微小的底层动作，层层累加到更高阶的行为，最终服务于宏观目标。人类的所有复杂行为都可以归入这一层级体系。例如筹办一场婚礼，必须在额叶的协调下构建巨大的决策树：确定各项任务的截止节点、预定教堂、聘请牧师、订购鲜花、确认宴会厅，而这一切又依赖于像“拿起电话打给牧师”这样琐碎的基础子程序。正是额叶将这些碎片统合为一个终极目标。然而，ADHD 摧毁的恰恰是行为的层级化组织能力；患者只能处理零敲碎打、断断续续的微小动作，缺乏将其黏合起来的能力。Barkley 指出，人们眼中的“注意力持续时间短”（short attention span），本质并不是注意力本身的问题，而是无法跨时间将行为组织成层级结构。 ### [01:16:08](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=4568s) 意图缺陷障碍与“知”与“行”的割裂 Barkley 指出，向前看并规划未来的能力被称为“意图”（intention），因此 ADHD 实际上应当被称为“意图缺陷障碍”（Intention Deficit Disorder, IDD）——因为无论患者怀有多么美好的初衷，他们都无法付诸实现。孩子早晨出门上学时，完全可以真心实意地向母亲发誓保证：今天绝对不再进惩罚角（time-out）、一定会听话、绝不跟同学打架、一定会写完作业，这些承诺绝无半分虚伪。然而仅仅过了一个小时，母亲就会接到学校的常规投诉电话，通知孩子又惹事被关了禁闭，必须立刻来学校接人。问题的根源绝非孩子不真诚，而是额叶无法围绕既定意图组织后续的行为。 从神经解剖学视角来看，人类大脑可以一分为二：后半部分负责获取知识，前半部分负责运用知识；后部关乎“认知”（knowledge），前部关乎“执行”（performance）。Barkley 形象地打了个比方：“ADHD, like a meat cleaver, just split your brain in half.”（ADHD 就像一把切肉剁刀，直接把你的大脑劈成了两半）。正因如此，患者懂多少道理根本无济于事，他们无法在现实中调动所学。在心理学上，这被称为“表现障碍”（performance disorder），它与技能多寡毫无关系： - **技能储备充足**：除非孩子成长于动物园、极端贫困匮乏的环境，或是从遥远饱受战火蹂躏的未落后地区被领养，否则他们完全掌握了同龄人应有的一切常识与技能。 - **执行严重脱节**：执行系统是理论与现实的接合点（where the rubber meets the road），而 ADHD 是“做到你所知之事”（doing what you know）的障碍，绝非“知晓该做什么”（knowing what to do）的障碍。 - **智力与行为相悖**：患者哪怕是地球上最聪明的人，依然会干出极其愚蠢荒唐的事，因为这关乎执行而非智力。 ### [01:18:34](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=4714s) 放弃无休止的技能培训，聚焦“表现发生点” 认清 ADHD 是执行障碍而非技能缺陷，必然推导出一个激进的干预原则：停止向孩子灌输那么多无意义的技能训练。Barkley 直言，当孩子交不到朋友时，家长往往假定他们不懂社交礼仪，于是花费每节 50 到 100 美元报名为期 12 周的社交技能训练营，或者送去密歇根上半岛的夏季社交夏令营。如果送孩子去夏令营纯粹为了散心娱乐、提升生活品质，那无可厚非；但若指望他们回来后社交技能焕然一新，则是彻底的误判。 治疗的关键必须转向“表现发生点”（point of performance）——即个体本该使用其已有知识、却未能调动出来的真实生活场景： - **干预必须处于表现发生点**：过去十年的核心研究发现，唯有对问题发生的自然环境节点做出调整，治疗才能真正奏效；任何脱离问题场景的异地干预都毫无价值。 - **缺乏泛化与维持能力**：把孩子从课堂拉出的个别辅导（pull-out services）、夏令营训练、特殊教育或每周一次的诊室心理咨询，其效果根本无法迁移或维持。Barkley 引用学者 Howard Abikoff 的经历指出，在 Abikoff 举办的社交技能训练班上，当天刚刚讲完愤怒管理与分享合作，下课打开门，就撞见两名孩子在电梯口为了谁按电梯按钮而大打出手。 - **重构物理环境**：操场上没有朋友，干预措施就必须落在学校操场；家庭作业写不完，战场是在家里的厨房餐桌，而不是心理医生的诊室。 ### [01:21:34](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=4894s) 增加问责机制：行为矫正的本质并非“教导” 面对 ADHD 的神经遗传学病因，不少家长会产生一种危险的误解。他们会在孩子因违纪被学校开除后找到医生，恳求医生去学校求情复学，理由是：“既然这是神经遗传疾病，孩子难道不应该免除后果与责任吗？”Barkley 对此给出了坚决的反驳：ADHD 绝不是对后果本身免疫，其核心症结在于“时间跨度”（delay）。真正让患者瘫痪的，是行为与自然后果之间拉得太长的时间差。 因此，应对之道绝非免除问责，而是要反其道而行之：“Increase accountability, not decrease it. Increase the frequency, immediacy, the salience, and the timing of consequences.”（要增加问责，而不是削减问责；要提高后果反馈的频率、即时性、显著性与时效性）。如果盲目主张免除责任，只会让病情恶化，因为现实中所有重大的自然后果都存在漫长的延迟。 诸如代币制（token economies）、图表、卡片、打卡贴纸等行为矫正方案（behavior modification / B mod），其真正目的根本不是去“教”孩子什么知识；把它们当成教学工具完全是一种用词不当。这些行为矫正手段的本质，是在原本延迟漫长的自然环境中人为“撒入”密集的人工后果，以此弥补其即时问责的缺失、提升行为动力，从而攻克这种实质上的“问责缺陷障碍”（accountability deficit disorder）。 ### [01:23:21](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=5001s) 行为矫正的本质：动机假体而非技能教学 Dr. Russell Barkley 深入剖析了行为矫正（behavior modification，简称 B-Mod）在临床与教育中的根本定位。他指出，通过在患者周围建立更频繁的问责机制（accountability），ADHD 的症状表现就会减少；相反，如果免除其行为后果，ADHD 的问题就会被放大。Barkley 强调，实施行为矫正存在两种完全不同的理由：一种是“教学性”（instructional），例如教导自闭症或智力障碍儿童掌握他们尚未掌握的技能；另一种则与教学毫无关系，而是“动机性”（motivational），其目的是弥补 ADHD 造成的“动机缺陷障碍”（motivation deficit disorder）。 这两种目的带来了决定性的差异：如果是为了教学，当儿童掌握该技能后，便可以撤除行为干预；但如果行为矫正是为了提供动机，就绝对不能撤掉——一旦撤除干预，动机也就随之消失。然而，绝大多数家长以及几乎所有学校教师都误以为行为矫正是用来教学的。因此，每当专家走进学校指导老师建立代币制（token system）时，老师提出的第一个问题往往是：“我必须做多久？他什么时候才能把这套程序内化？”对此，Barkley 的回答是极其明确的两个字：“绝不”（never）。只要孩子在这个班级里，老师就必须持续安排人造的即时后果来替代滞后的后果，否则孩子就不会配合完成任务。 为了让听众彻底理解这一逻辑，Barkley 用无障碍坡道作了一个形象的比喻。建筑物前的无障碍坡道是一项假体（prosthesis），用于减少肢体残疾者的行动受限，让坐轮椅的人能够进入建筑。没有人会对轮椅使用者说：“你用这个坡道成功进出了 30 天，我是不是能把坡道拆了？你内化这个坡道了吗？”正如 Barkley 所言：““坡道从来都不是用来教学的，对吧？坡道是一个假体。假体是一种人工手段，用来减少障碍带来的致残性后果。””同理，任何星号表、代币系统等行为矫正手段都是假体，ADHD 患者永远需要比常人更频繁的即时后果，才能维持在同等的执行表现水准上。 ```mermaid flowchart TD accTitle: 行为矫正的两种目的对比 accDescr: 对比教学性与动机性行为矫正，说明ADHD干预属于不可撤除的假体。 subgraph Instructional["教学性目的 (自闭症/智力障碍)"] A["传授未掌握的技能"] --> B["习得新技能"] B --> C["可安全撤除行为矫正"] end subgraph Motivational["动机性目的 (ADHD)"] D["弥补神经生物学上的动机缺陷"] --> E["提供人造外部即时后果 (坡道/假体)"] E --> F["维持在正常执行水准"] F -.->|"一旦撤除干预"| G["动机彻底消失 / 绝不可内化撤除"] end ``` - 面对教师关于代币制何时能内化的疑问，Barkley 的态度极其坚决：““只要他还在你的班级里，你就必须安排人造后果来替代滞后后果；如果你不这么做，他就不会为你干活。”” - 假体（prosthesis）的核心定义是减少残疾造成的失能后果，而非试图通过训练来消除缺陷；使用坡道再久也不会让肢体残疾者不再需要坡道，行为矫正同理。 --- ### [01:26:04](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=5164s) 照料者的角色与糖尿病类比：以管理预防继发性伤害 基于所有干预都必须发生在“表现点”（point of performance）且属于环境假体这一事实，Barkley 指出，治疗方案中最关键的核心人物并非专业医生，而是照料者——即父母与教师。任何成功干预的核心，都在于这些照料者对残障个体的同情与理解，以及他们愿意做出假体性环境调整的意愿。如果缺乏这种投入与共情，无论心理治疗师或临床医生的水平有多高，干预都注定失败；专业人员必须让照料者成为真正的利益相关者。 在向就诊家庭解释 ADHD 时，Barkley 最常用的类比是糖尿病。糖尿病是一种慢性疾病，医学上的目标是通过管理来减轻症状，其根本目的是避免“继发性伤害”（secondary harm）。控制糖尿病并不是为了根除它，而是为了防止因未妥善管理胰岛素而导致的失明、心肌萎缩、猝死、坏疽以及肢体被截肢等可怕后果。 Barkley 强调，ADHD 的干预逻辑与糖尿病如出一辙：““我们管理 ADHD 是为了防止你经历那些更令人发指的后果，而不是为了摆脱它。””传统将 ADHD 仅仅视为“注意力问题”的视角对干预毫无指导价值（听到别人说注意力不集中，医生往往不知所措，总不能只建议多喝咖啡）；但如果将其准确定位为“执行功能障碍”（executive disorder），就能在任何表现点立即衍生出具体的应对原则。 - 治疗的成败取决于照料者（父母与教师）的慈悲心及其搭建假体环境的意愿，专业人员的医术无法弥补照料者参与的缺失。 - 糖尿病与 ADHD 的对比：两者皆为慢性障碍，治疗目标均为长期的日常管理，核心在于预防灾难性的继发伤害，而非彻底“根治”。 --- ### [01:28:28](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=5308s) 补偿执行障碍：外化工作记忆与时间可视化 当把 ADHD 理解为执行障碍时，环境调整便有了明确的方向。Barkley 针对该障碍提出了具体的代偿法则，首要核心便是：既然 ADHD 患儿无法在头脑中自主停顿并保持信息，家长和老师就“绝对不要强求他们去凭脑子记”。必须使用物理性的外部信息形式——便签、标牌、符号、图表、视觉提示与备忘录——来作为工作记忆的替代品。重点不在于具体采用何种形式，而在于其底层的原理（the why）：把本应由大脑在当下调取的关键信息，直接放置在个体的外部视野之中。 为了说明这种假体的必要性，Barkley 幽默地拿年龄增长打趣。他提到自己当时 59 岁，与 55 岁以上的群体以及绝经前期的女性一样，工作记忆都在衰退，满屋子贴便签，去超市前都要反复核对。他的妻子甚至在车里备了一个数字录音机，随时口述记录防止忘买东西。而对于患有 ADHD 的成年人，Barkley 给出的硬性规则是：口袋里必须时刻随身携带纸质记事本与笔，一旦答应了事情或别人提出了要求，必须立即写在记事本上，“就如同焊接在身上一样”。他特别提醒，纸质笔记本往往比智能设备更有效，因为患者经常会忘带手机、忘记开机或忘记录音；甚至可以像摩托车帮派将钱包挂在腰带链条上那样，把笔记本锁在裤子上。 第二个核心缺陷是患者缺乏“内部时钟”（internal clock）。Barkley 强调：““你没有时间感；因此，如果我交给你一件涉及时间的事情，我就必须给你一个计时器。””对于年幼儿童，普通的厨房定时器非常好用；也可以使用每 5 分钟蜂鸣一次的震动手表，或在专业网站（如 addwarehouse.com）购买带数字定时的口袋震动提示器。超出几分钟到半小时的任务，则必须依赖日程本、PDA 掌上电脑或一周一览日历，让患者对计时器和日历形成功能性依赖。 第三，ADHD 患者无法感知“未来的逼近”。面对读书报告或科学实验这类长期任务，家长绝不能站在一旁反复唠叨催促（例如天天问“你暑假阅读做完了吗？”、“下周交的报告写了吗？”）。这种做法无异于跑到精神病院指责精神分裂症患者居然在产生幻觉一样荒谬，因为无法对未来进行组织本就是 ADHD 的残疾所在。正确的策略是把未来彻底拆解为“婴儿步”（baby steps），一日一小步：今天只读三页、今天只写四句话，写完立刻给予 15 个代币的即时强化，用微小的当下推进来代替遥远的未来目标。 - 补偿工作记忆的核心原则是“外化”（externalize），将关键信息转化为视觉可见的实体，纸质口袋笔记本往往比容易遗忘/丢失的数码设备更为稳定。 - 时间管理必须依赖外部设备（定时器、震动提醒器、日程表、周历），使时间流逝物理具象化。 - 应对长期项目的策略：严禁对未来空头施压，必须将长期任务切碎为每日微量步骤，并绑定即刻的外部强化（如代币奖励）。 ### [01:32:45](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=5565s) 将未来切成碎片：ERO 联结模型与即时动机机制 面对时间管理障碍，最核心的应对策略就是将未来拆解成极小的片段。Russell Barkley 博士用“ERO”模型来解析人与未来的互动：环境事件（Events, 也就是迎面而来的情况）、应对反应（Responses, 个体准备采取的行动）以及结果（Outcomes, 行为所带来的后果或奖惩）。如果 E、R、O 三者紧密咬合、即时发生，大脑甚至不需要动用额叶皮层，多动症（ADHD）患者完全能够处理得游刃有余——电子游戏正是绝佳的范例。然而，一旦引入时间差，例如老师布置一篇读书报告，要求 30 天后提交，老师再花一周时间批改，这就等于在事件与反应之间拉开了整整一个月的鸿沟，在反应与结果之间又隔了一周时间。对于 ADHD 患者而言，这种时间跨度会导致其执行功能出现断崖式瘫痪。解决之道就是把这三者重新聚拢，“架设跨越时间的小型 ERO 桥梁”，用走小碎步的方式拆分任务。 ```mermaid flowchart TD accTitle: ERO 架构对比图 accDescr: 对比常规远期任务中 ERO 被时间拉扯导致的执行断裂，与切分后即时反馈的小型 ERO 桥梁。 subgraph BrokenFlow["远期任务（额叶瘫痪）"] E1["事件 (Events)<br/>布置30天后报告"] -->|"30天间隔 (断裂)"| R1["反应 (Responses)<br/>阅读与撰写"] R1 -->|"7天批改 (断裂)"| O1["结果 (Outcomes)<br/>最终成绩与反馈"] end subgraph LinkedFlow["即时桥梁（外部化支持）"] E2["微事件<br/>读完这一章"] -->|"即时准备"| R2["微反应<br/>写下3张卡片"] R2 -->|"即刻兑现"| O2["微结果<br/>获得代币或点数"] end ``` 谈及第四项执行功能缺陷——情绪与动机障碍，Barkley 博士强调所有动机都必须外部化。父母与教师必须停止无休止的抱怨和不解，别再纠结为何必须给他们提供外部诱因才肯动工。普通儿童拥有内在动机，而 ADHD 儿童没有；给予代币、点数或奖励不会破坏他们所谓的“为了成为优秀公民而做好事”的道德纯洁性，因为这种内在说辞对 ADHD 根本不起作用。Barkley 博士风趣地打了个比方：“ADHD 儿童就是唐纳德·特朗普（Donald Trump）的化身，最好得有一笔交易（there better be a deal）。要是没有交易，事情就免谈。”家长必须践行斯蒂芬·柯维（Stephen Covey）倡导的“双赢”思维，通过即时兑现代币、特权甚至现实利益来驱动行动，Barkley 博士还开玩笑说自己的药效好像正在减退，引来全场会心的笑声。 - “ADHD children do not [have internal motivation]. So, don't worry that by paying them tokens for doing their reading or their assignments you're somehow going to pervert a sense of doing things for their own reward or value.” —— Russell Barkley 博士解释为何不能指望 ADHD 孩子靠纯内在动机行事。 - “The ADHD child is Donald Trump incarnate and there better be a deal. And if there is no deal, it ain't getting done.” —— Russell Barkley 博士形象地指出必须为 ADHD 孩子建立明确的奖惩交换机制。 --- ### [01:35:10](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=5710s) 心理运作的具象化：用双手解决思维难题 第五项执行功能是“心理运作（mental play）”，即在大脑内部灵活调动、重组思维内容，以创造多元可能性的能力。ADHD 患者的工作记忆容量受限，无法在脑中同时抓取并处理多重信息，因此很难完成心算、数字倒背（digit span backward）或像“西蒙说（Simon）”这样的音乐记忆序列游戏。由于无法在脑海里调度这些素材，他们无法自发完成复杂的规划与问题解决。应对这一难题的关键策略依然是“外部化”——将脑力思考转变为手动化、物理化的实体操作。 解决数学问题时，应当为他们提供实体教具：一堆玻璃珠、实体数轴、算盘或计算器，让他们像人类祖先最初算数那样用双手去触摸和计算，将这些实体作为思维的义肢。面对撰写故事或长篇文章等言语任务时，则可以提供一叠 3x5 英寸的索引卡片，让孩子把大脑切换到“信息倾倒（brain dump）”模式：想到任何与主题相关的点子就立刻写在一张卡片上，不管顺序和逻辑，一卡一想法；写完后，协助他们用双手在桌面上物理移动这些卡片，重新排列组合，理顺故事脉络和大纲。在电脑上使用 Word 的剪切、粘贴和拼写检查同样也是这一思路的延伸。Barkley 博士进一步推测，这或许解释了为何如此多的 ADHD 患者最终流向了技工与手艺行业（如木匠、水管工、园艺师、砌砖工、电工或钢琴调音师等）——除了对高阶学历门槛的要求较低外，这类工作高度依赖双手进行物理操作，完美规避了纯脑内虚拟推演的短板。 - “Make the mental information physical in some way, and then they might be able to do it.” —— Russell Barkley 博士阐明如何克服工作记忆缺陷并进行复杂创作与规划。 --- ### [01:37:29](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=5849s) 共病普遍性与未受干预 ADHD 的长期人生代价 在进入短暂的 10 分钟中场休息之前，Barkley 博士着重强调了 ADHD 的共病特征：单纯的 ADHD 极其罕见，高达 80% 的患病儿童和成年人会同时患有至少一种其他精神障碍，50% 会伴随至少两种其他障碍。治疗方案绝不能局限于单纯应对 ADHD 本身，而必须全面覆盖伴随的各类心理与行为问题。 中场休息归来后，Barkley 博士基于自己的长期纵向追踪研究和其他学者的成果，详细列举了未经干预的 ADHD 会在人生各阶段引发的连锁破坏。学业是遭受重创的首要领域：留级极其普遍，整整三分之一的人无法完成高中学业直接辍学，最终能从大学毕业的仅有 5% 至 10%。学业上的受挫随后会直接传导至职场表现，并引发严重的驾驶风险。北美地区导致车祸的首要原因就是车内注意力分散，而 ADHD 本质上就是一种注意力涣散障碍。患者在驾驶的所有维度上均表现惨淡：超速罚单更多、车祸发生率更高、多重连环事故更严重，其驾照被吊销的几率是普通人群的三倍。针对这种高危状态，加拿大儿科协会（Canadian Paediatric Society）已正式提出指南建议，一旦确诊达到中度或以上严重程度的 ADHD 青少年开始学车，驾驶期间必须强制服药。 - “There is no disorder that interferes with driving to the degree that ADHD does.” —— Russell Barkley 博士指出 ADHD 对驾驶安全构成了所有心理与精神障碍中最为严重的破坏。 - “Why is that? Because you can kill yourself. And you can kill other people as well with a motor vehicle and we don't want to see that happening.” —— Russell Barkley 博士强调让 ADHD 患者在驾车时接受药物治疗的生命安全底线。 --- ### [01:40:09](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=6009s) 财务管理失控、人际破裂与高风险行为 伴随成年独立生活的展开，财务管理成为另一个极易崩溃的重灾区。当冲动控制严重不足的个体离开家庭，开始工作并接触到信用卡、个人借贷和汽车贷款时，灾难往往接踵而至。他们经常拖欠或漏缴各种账单，导致水电燃气被强制断供，车辆因断供被金融机构收回，个人信用评级一塌糊涂。Barkley 博士调侃道，如果把信用卡发给一个毫无自我控制能力的人，这简直是灾难的源头；他还不忘借题发挥讽刺华尔街金融危机：“这年头我们真该好好管管这个，每一个在 AIG（美国国际集团）工作的人大概都该吃点药。”针对这些群体的财务管理，必须建立极具约束力的外部监督机制。 在社交与情感生活方面，成年 ADHD 患者常报告自己难以维系长期的亲密关系或伴侣关系，由于持续的冲动、遗忘和情绪失调，其离婚率显著高于普通人群。在性行为模式上，研究发现他们并没有出现更高比例的性偏好障碍（如恋童癖或异装障碍等并无增加），但呈现出极高程度的“高风险性行为”。患者通常比同龄青少年提前一年左右初尝禁果，并且由于无法在单一稳定关系中长期停留，伴侣数量显著更多，从而极大地推高了意外怀孕与性传播疾病的风险。 - “Social problems are going to continue into adulthood for many, though not for all of them. They often as adults describe themselves as having trouble sustaining long-term relationships, particularly dating and marital relationships... and we will see that they do experience divorce at a higher rate than other people do because of these difficulties.” —— Russell Barkley 博士阐明 ADHD 患者在成年期维系婚姻与伴侣关系所面临的严峻考验。 ### [01:41:51](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=6111s) 冲动行为的严重后果与终身治疗的必要性 巴克利博士（Dr. Russell Barkley）指出，患有 ADHD 的青少年在恋爱关系中往往难以持久，同时由于极度冲动，他们经常不采取避孕措施，这导致少女怀孕的概率暴增了十倍。事实证明，目前没有任何指标比 ADHD 能更准确地预测青少年怀孕。在巴克利博士开展的追踪研究中，高达 32% 的 ADHD 男孩在 19 岁前就成了父亲，而 68% 的 ADHD 女孩在 19 岁之前至少怀过一次孕。这是一种极易导致个体过早成为父母的神经发育障碍。这种早育现象在这些患儿的父母身上同样屡见不鲜，原因在于父母往往也患有 ADHD，而成年 ADHD 本身就会导致生育年龄显著提前。与此同时，伴随而来的还有四倍之高的性传播疾病（STD）发病率。 如果不加以干预，这群人在科学界所研究的每一项主要生命活动中都会遭遇功能受损。巴克利博士强调，迄今为止，医学界还没有发现任何一个生活领域能够完全免受 ADHD 的负面影响。正因如此，临床上强烈呼吁必须进行跨每周、跨全年、尤其是贯穿整个青春期的长期系统性治疗。遗憾的是，目前大多数患儿即便服药，治疗时间也仅维持三年或更短，参加干预项目的时长同样只有区区数年。巴克利博士直言不讳地指出，各项研究一致表明：“在改变这些个体的整个人生轨迹方面，仅在童年期进行的治疗毫无用处。”（“And what we have found in these studies is that childhood only treatment was useless. Useless in terms of changing the life course of these individuals.”） - **青少年早孕风险**：ADHD 青少年怀孕率增加 10 倍；19 岁前男性致孕率达 32%，女性怀孕率达 68%。 - **性传播疾病风险**：性传播疾病感染率高出普通人群 4 倍。 - **治疗时限的误区**：大多数儿童的药物或干预治疗在 3 年内就草草中断，而局限于童年期的短期治疗无法改变长期的成年期不良预后。 --- ### [01:43:18](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=6198s) 核心评估法则：落后 30% 的“执行年龄”法则 要理解为何这些功能障碍会一路延续至成年期，就必须认清 ADHD 的本质是自我调节能力的障碍，且这种缺陷是量化可测的。巴克利博士在诊所中向无数家庭传授了一条行之有效多年的经验法则——**30% 滞后法则**：平均而言，ADHD 儿童的心智成熟度比其生理年龄落后约 30%（部分患儿滞后程度甚至更高）。这意味着，如果一个孩子生理年龄是 10 岁，那么他的自我控制能力、专注坚持的时间、工作记忆容量、脱离成人监管能够独立维持的时间，以及自我组织能力，实际上仅仅相当于一个 7 岁儿童的水平。 家长必须学会将期望值降至孩子的“执行年龄”（Executive Age）或“自我调节年龄”。如果一个 10 岁孩子的自我调节能力只有 7 岁，那么在布置家庭作业、分配家务、社交活动以及给予独立自由度时，就绝不能像对待正常 10 岁儿童那样放手。巴克利博士严肃地对台下的父母们表示：“如果你期望的比这还要高，那你才是我的问题所在，因为是你在制造冲突。”（“And if you are expecting more than that, you're my problem. Because you're causing the conflict.”）这种盲目拔高期望的家长，就像要求阅读障碍患儿拥有正常阅读能力、要求轻度智力缺陷儿童具备正常的认知与自理能力一样不切实际。如果环境没有任何改变，孩子在执行功能上就会实打实地滞后 30%；家长若想让他们承担更多责任，就必须主动重构周围环境。 ```mermaid flowchart LR accTitle: ADHD 30% 执行年龄滞后法则对比 accDescr: 对比 ADHD 个体的生理年龄与其对应的执行功能自我调节年龄及对应场景。 subgraph Chrono["生理年龄 (Chronological Age)"] C1["10 岁儿童"] C2["16 岁青少年"] C3["18 岁大学生"] C4["14 岁少女"] end subgraph Exec["执行年龄 (落后 30%)"] E1["7 岁自控力（需持续监督）"] E2["11 岁心智（驾驶机动车极度危险）"] E3["12 岁心智（大学需全方位辅导与监管）"] E4["9 岁心智（绝不可单独看护婴儿）"] end C1 -->|"30% 法则"| E1 C2 -->|"30% 法则"| E2 C3 -->|"30% 法则"| E3 C4 -->|"30% 法则"| E4 ``` 巴克利博士列举了若干极具冲击力的现实案例来说明 30% 法则的应用： - **16 岁考驾照**：让一个 16 岁的 ADHD 孩子开车，本质上等于把机动车钥匙交到了一个 11 岁孩子的手里，其严重的驾驶后果完全在预料之中。 - **18 岁上大学**：那些有幸进入大学的 18 岁 ADHD 学生，其执行年龄仅有 12 岁。如果大学校园里到处是 12 岁的初中生，学校会怎么做？校园必须提供对应的融通支持：更多的手把手辅导、更严格的问责机制、向学生支持中心密集打卡（例如每天四次核对课业进度）、提供更多课程材料、与更成熟自律的学长组成互助学习小组，并安排居住在无烟酒宿舍。否则，他们往往第一学期就会直接挂科退学。 - **14 岁做临时保姆（Babysitting）**：哪怕 14 岁的女儿拿到了红十字会的保姆培训合格证书，也不能让她独自照看 3 个月大的婴儿，因为她的执行年龄只有 9 岁。现实中已有大量残酷的法律判决案例：部分十几岁甚至二十岁出头的 ADHD 青少年在照料哭闹婴儿时，由于极度缺乏耐心、心智不成熟以及情绪调节失控，最终在愤怒中失手致死婴儿。 --- ### [01:47:33](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=6453s) 综合治疗的四大核心支柱与药物的关键价值 巴克利博士强调，任何一个有效的 ADHD 综合治疗方案都必须包含以下四大核心要素，缺一不可： 1. **全面且专业的评估**：必须寻求专业且经验丰富的专家进行评估，无论是发育儿科医生、儿童精神科医生、儿童心理学家还是行为神经学家皆可，核心在于其对 ADHD 的临床经验与培训水平，而非学位名称。由于高达 80% 的 ADHD 个体会共患至少一种其他心理或行为障碍，精准的评估是制定后续治疗的前提。 2. **家庭充分的自我教育**：家长必须彻底搞懂 ADHD 的机制，将自己培养成专家，否则根本无从应对日常挑战。 3. **药物治疗作为首要干预基石**：巴克利博士直截了当地指出：“药物是我们目前拥有的最有效的手段；无论你喜欢与否，这都是一个客观事实。”（“Third, you need to understand that medication is the most effective thing we have. And that doesn't matter to me whether you like that or not. That is a statement of fact.”）过去临床界曾盲目坚持“先试遍其他一切心理与行为干预，失败后才考虑用药”，结果导致 80% 的患者在兜兜转转失败后最终依然需要用药。先用药物改善大脑神经机能，反而能使患者对后续的心理社会学与教育干预更加敏感有效。 4. **针对“执行表现点”的环境重构与假体辅具（Accommodations）**：利用外部化信息、清单、提示物等五大策略重构现场环境，搭建“认知假体”，让孩子能够将脑中已有的知识真实地表现出来。 巴克利博士特别解释了为何高达 80% 的 ADHD 儿童在成长发育过程中都会接受药物治疗。行为干预固然有其价值，但在现实生活的无数场景中，人类根本无法实时实施行为干预。例如，前一天晚上在代尔塔酒店（Delta Hotel）刚好有一场高中返校舞会（Prom），当一个 ADHD 孩子在半夜驾车回家的路上超速飞驰时，家长根本不可能坐在副驾驶座上根据他是否遵守限速来实时分发奖励代币。巴克利博士斥责那种“行为干预完全可以替代药物”的观点是荒谬愚蠢的，药物能够弥补现实监管无法触及的时空空白。 --- ### [01:50:15](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=6615s) 家长的第一重角色：成为“科学型家长” 认识到 ADHD 是一种比过去认知中更为深重且具有全面破坏性的发育障碍后，家长应当在日常生活中承担起三重关键角色（详见其著作《掌控 ADHD》/ *Taking Charge of ADHD*）。 在这一部分，巴克利博士重点阐述了第一重角色：**成为科学型家长（Scientific Parent）**。这意味着家长必须主动让自己成为该领域的专家，在 ADHD 相关知识的掌握上达到不逊色于专业人员的水准。 巴克利博士告诫父母，真正的客观事实与科学真相绝非来自单一的网页、某篇帖子或孤立的信息源，而是需要广泛研读权威文献，在不同的信息源之间进行横向比对与整合。只有那些在多个高质量渠道中反复出现、互相印证的信息，才是值得信赖的事实。家长应该积极查阅诸如 CHADD（chadd.org）、ADDA（add.org）以及 CADDAC（caddac.ca）等权威组织的专业资料，保持广泛深入的学习，全面洞察这一障碍的底层机理。 ### [01:51:02](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=6662s) 成为实验者与敏锐的怀疑论者 Dr. Russell Barkley 强调，养育 ADHD 患儿的过程就像照料糖尿病患儿一样，家长必须由内而外地透彻了解这种障碍，才能给予适当的应对与代偿。然而，在具体应对手段上，家长必须像科学家一样去不断“做实验”。市面上存在成百上千种干预手段，但没有任何一种能够通用于所有儿童。养育 ADHD 患儿是一个不断“测试、调整、再测试、再调整”的循环过程，没有任何人能够一上来就做到完美。某位家长用某种方法见效，换到另一个孩子身上可能完全没用；有的孩子适合 Concerta（专注达），而另一些孩子则需要 Adderall、Vyvanse 或 Strattera（择思达），即便用同一种药，起效剂量也大相径庭。因此，Dr. Barkley 提醒家长不要因为代币奖励系统（token system）或暂停法（time out）初次尝试失败就感到气馁，必须保持耐心，持续探索最适合自己孩子的方案。 除了成为实验者，家长还必须戴上“怀疑论者的帽子”，保持高度的批判性思维。Dr. Barkley 提到，他在演讲当天早晨在 Google 上搜索“ADHD”，跳出了整整 1400 万条搜索结果，普通家长根本不可能在这片庞大的“垃圾堆中淘出钻石”。互联网上充斥着无数伪科学与商业噱头，比如所谓的磁疗床垫、铜手镯、银杏叶提取物、Omega-3/Omega-6 脂肪酸补剂、碧容健（Pycnogenol）抗氧化剂，甚至拉斯维加斯还有一家诊所声称能为全家做诊断并附赠赌场筹码。Dr. Barkley 告诫大家，如果一项信息在多个可靠的专业来源中无法得到一致印证，那它极大概率是假的；这与理财投资同理，如果某件事听起来美好得令人难以置信，那它往往就是骗局。家长必须建立严格的信息过滤机制，以审慎态度剔除伪科学。 - 应对 ADHD 是一种反复试错的动态过程：“测试、修正、测试、修正（test, revise, test, revise）”。 - 互联网上关于 ADHD 的信息超过 1400 万条，充斥着未经证实的替代疗法与商机噱头。 - Dr. Barkley 对家长提出的核心判断法则：“If you are not hearing this information reliably across different sources, it probably isn't true.”（如果你没有从不同的可靠来源一致听到这一信息，它大概率不是真的。） --- ### [01:53:19](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=6799s) 成为“执行型家长”，认领障碍并坚决倡导 Dr. Barkley 提出的下一项核心法则是：家长必须成为“执行型家长”（executive parent）。他指出，许多家庭最艰难的一步在于真正从心理上“认领（own）”这种障碍——停止抱怨、硬起心肠、直面现实。不少父母内心总抱有一丝侥幸与退缩，指望在网络上找到某种“灵丹妙药（silver bullet）”，以为一试便能彻底解决所有问题，让孩子变回“正常人”。然而现实中根本没有这种神丹妙药。Dr. Barkley 对 ADHD 成人患者也说过同样的道理：理解 ADHD 是一回事，但认领它、将它接纳为你自身的一部分是另一回事。ADHD 并不代表个体的全部，它只是人类 400 多项天赋特质中的一小部分缺陷，本身并不附带任何天赋。虽然像奥运冠军 Michael Phelps（迈克尔·菲尔普斯）或电视节目《Extreme Makeover: Home Edition》的主持人 Ty Pennington 都是 ADHD 患者，但他们的杰出成就归功于自身擅长并热爱的其他才华，而不是 ADHD 本身。家长要做的，是帮孩子找到能弥补其缺陷的优势特质，而不是将优秀归结于障碍，更不能寄希望于障碍自行消失。 唯有彻底认领这项障碍，家长才能真正成为孩子最坚定的倡导者（advocate）。这也是 Dr. Barkley 将自己的著作命名为《Taking Charge of ADHD》的原因。在现实中，他常常看到家长在学校评估会议上被满桌拥有专业头衔和学历的人吓倒，一言不发。Dr. Barkley 严厉提醒家长：“这些人是在为你工作，你是纳税人，这是你的孩子，你应该主持这场会议。”家长应带着笔记本和录音机走进会议室，开门见山地主导议程，逐一询问任课老师的具体情况。一旦专业人士抛出像“Woodcock-Johnson 心理教育 IQ 测试”等令人费解的术语，家长必须立刻打断会议要求对方讲人话，因为这往往只是专业人士在炫耀行业黑话。最终的决定权永远掌握在家长手中，家长绝不能签署任何自己感到不舒服或不切实际的方案。 ```mermaid flowchart TD accTitle: 执行型家长的行动逻辑 accDescr: 展示从心理认领障碍到在现实中为孩子主导权益倡导的完整演进路径。 subgraph Mindset["心态确立（认领障碍）"] A["摒弃“灵丹妙药”幻想"] --> B["认领并接纳 ADHD"] B --> C["寻找其他优势进行代偿"] end subgraph Action["现实行动（主动倡导）"] C --> D["主导学校与专业会议"] D --> E["拒绝行业术语与黑话"] E --> F["掌握最终决策与方案筛选权"] end ``` - Dr. Barkley 谈到家长直面现实的紧迫性：“You need to stop whining, suck it up, man up, and own this disorder in this child.”（你必须停止抱怨，咬牙承受，像个男子汉一样站出来，直面并认领这个孩子的障碍。） - 针对家长在学校会议上的畏缩，Dr. Barkley 强调权责关系：“And I have to remind parents, these people work for you. You are the taxpayer. This is your child. You should be running this meeting.”（我必须提醒家长，这些人是为你工作的。你是纳税人。这是你的孩子。你应该来主持这场会议。） - 真实案例：Dr. Barkley 的外甥在确诊后，外祖父母坚决反对服用 Concerta，甚至扬言要以虐待儿童罪将父母告上法庭；这证明家长必须主动与医生和专业团队沟通家庭阻力，医生才能提供具体的破局策略。 --- ### [01:57:52](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=7072s) 践行高效能原则与打破“塑造孩子”的幻觉 确立了倡导者角色之后，Dr. Barkley 提出的第三项法则是学习 Stephen Covey 的家庭原则。他强烈推荐阅读《高效能家庭的7个习惯》（The 7 Habits of Highly Effective Families），并指出抚养残障或发展障碍儿童的家庭比普通家庭更迫切需要这些法则。Covey 在书末提供了一幅形似沙漏、由两个倒三角构成的图表，概括了全部七个习惯。Dr. Barkley 建议家长将这一图表复印下来，直接贴在浴室的镜子上，这样每天早晨剃须或化妆时，这些原则都会停留在视野角落，作为开启一天的行为提醒。 随后，Dr. Barkley 描绘了一幅更为宏大的背景认知画布：当代父母必须清醒认识到一个早已被祖辈熟知、却被现代育儿文化彻底遗忘的生物学事实——“你无法设计你的孩子（You do not get to design your children）”。从演化与自然法则来看，生命的繁衍机制绝不会允许一个物种的某一代被其上一代单方面完全塑造或左右。然而，现代社会充斥着各种荒唐的育儿迷信，诸如“莫扎特效应”——让人误以为怀孕时对着子宫播放古典音乐就能生出天才，或者只要在婴儿床上挂满刺激玩具，就能让孩子的神经元疯狂增殖。Dr. Barkley 告诫父母，必须彻底破除这种能将孩子塑造成某种预设模样的虚妄幻想。 - 建议家长将《高效能家庭的7个习惯》核心图表贴在卫生间镜子上，作为每日行为准则的视觉提示。 - Dr. Barkley 论及演化与亲子本质：“Evolution would not have allowed a generation of a species to be so influenced by the previous generation. It hasn't happened and it doesn't happen and it especially doesn't happen in children. You do not design your children.”（演化绝不会允许一个物种的这一代受到上一代如此巨大的单向塑造。这种事从未发生过，现在没有发生，在孩子身上尤其不可能发生。你根本无法设计你的孩子。） ### [01:59:49](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=7189s) 环境刺激的阈值与“工程师 vs 牧羊人”教养观 Russell Barkley 博士首先探讨了早期环境刺激与大脑发育之间的关系。许多家长陷入误区，误以为只要不断增加外界刺激，孩子的大脑突触就会爆炸式生长，从而成为数学天才。然而，事实并非如此。刺激环境固然优于匮乏环境，但这绝不意味着“刺激越多就越好”。大脑发育存在一个基本阈值，只要满足正常发展所需的基础刺激（98% 的家庭早已达到这个水准），其余的发展很大程度上就已经脱离了家长的掌控。博士风趣地调侃道，这种“既然一点点有效，那大量灌输必然更好”的心态，纯粹是一种北美特有的育儿执念，法国人对待孩子可绝没有这种盲目的狂热。 根据近二十年来在神经影像学、行为遗传学、发育心理学以及神经心理学领域的扎实研究，博士给出了一个核心结论：“你的孩子出生时就带有超过 400 种心理特质，这些特质会随着他们的成熟而逐渐显现，并且它们与你毫无关系。”因此，家长试图去“工程化设计”孩子的个性、智商（IQ）或学业成就的企图，在科学上根本站不住脚。孩子绝不是一块任由父母随意书写的“白板”（Blank Slate）。如果想深入了解这一领域，可以阅读斯蒂芬·平克（Steven Pinker）的名作《白板》（*The Blank Slate*）。孩子实际上是整个家族谱系的“基因马赛克”（Genetic Mosaic），汇集了家族代代相传的独特特征组合。 基于此，Barkley 博士提出了深刻的育儿隐喻——放弃“工程师”视角，接纳“牧羊人”角色： ```mermaid flowchart TD accTitle: 工程师视角与牧羊人视角对比 accDescr: 对比传统工程师育儿观与科学的牧羊人育儿观在角色定位、控制范围及心理结果上的差异。 subgraph Engineer["工程师视角（错误模式）"] E1["视孩子为白板/机械"] --> E2["试图全盘设计性格与智力"] E2 --> E3["对一切成败全权负责"] E3 --> E4["背负前所未有的内疚与焦虑"] end subgraph Shepherd["牧羊人视角（科学模式）"] S1["承认孩子独特的基因特质"] --> S2["负责选择优良牧场与环境"] S2 --> S3["提供滋养并抵御外部伤害"] S3 --> S4["卸下自责，享受孩子的成长历程"] end ``` - **内疚感的根源**：现代父母之所以承受着前所未有的内疚，正是因为工程师心态让他们误以为孩子的残疾或不足是自己没有做好导致的。 - **牧羊人的真正职责**：“牧羊人不会去设计绵羊。”牧羊人拥有强大的力量，负责挑选水草丰美的牧草地（设计环境）、提供充足滋养并保护羊群免受伤害，但没有任何牧羊人能把一只绵羊改造成猎犬。 ### [02:02:49](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=7369s) 摆脱盲目内疚：家庭外环境与遗传学的决定性影响 将自己重新定位为牧羊人，不仅符合生物学事实，更能给父母带来精神上的彻底解脱。父母应当学会退后一步，“倒上一杯夏多内白葡萄酒（Chardonnay），踢掉拖鞋，舒舒服服坐下来欣赏这场秀”，因为孩子的童年转瞬即逝。家庭内发生的事情根本无法单独决定孩子一生的轨迹。 Barkley 博士引用了朱迪斯·里奇·哈里斯（Judith Rich Harris）在 1998 年划时代著作《教养的迷思》（*The Nurture Assumption*，录音口误为 1996 年）中的经典论点：只要排除极端的虐待、忽视和严重营养不良，父母对孩子一生最大的影响，其实发生在你选择搬到哪里居住的那一刻，而不是你在家中关起门来所做的具体教养细节。家庭外部的环境力量——同伴群体、其他成年榜样、社区资源、学校网络——在塑造孩子人生轨迹方面的力量，远远超过家庭内部的影响。 科学界在双胞胎追踪研究和收养研究中反复验证的两大事实，彻底粉碎了“父母决定论”： 1. **父母影响力的断崖式衰减**：父母教养方式对孩子行为差异的影响在 7 岁前达到顶峰；7 岁到 12 岁急剧下降；15 岁之后，父母家庭教养对青少年行为差异的解释度仅剩可怜的 6%；而在 21 岁之后，这个数字变成了 0%。“在 21 岁之后，父母的教养方式对任何心理特质都不再产生任何影响。”（孩子所掌握的客观知识确实来自后天环境的传授，但其底层特质、能力与人格结构绝非父母所造）。 2. **收养研究的铁证**：在所有严谨的收养研究中，被收养孩子自身的任何心理特质，与其养父母的特质之间均呈现“零相关”。 正如 Barkley 博士所总结：“如果你认为教养具有如此强大的塑造力，请拿出证据来证明它；否则，请退后一步，接纳你作为牧羊人的角色，把牧羊工作做好，并享受这场演出。”对于 ADHD 或其他发育障碍儿童的父母而言，这意味着你不仅无法揽下全部功劳，但也绝对不必背负莫须有的罪责——你并没有造成孩子的 ADHD。 ### [02:06:02](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=7562s) “少说多做”：行之有效的执行力干预原则 由于执行功能存在神经生物学缺陷，ADHD 患儿无法依靠内部意志力进行自我约束，因此父母必须在环境中构建远比普通家庭更严格、更一致的规则与后果系统。但建立这些规矩并不是为了“把 ADHD 从孩子身上工程化地剔除”，而是为了最大程度减轻 ADHD 给他们带来的功能性损害。 针对日常管教，博士给出了极其明确且直截了当的建议： - **拒绝碎碎念（Act, don't yak）**：“ADHD 并不是‘信息匮乏症’，所以请大家友善地闭上嘴巴。”父母往往陷入幻觉，以为只要自己再说上一句话，就能说服孩子服从命令。事实上，父母说得越多、唠叨得越凶、讲的大道理越长，其影响力就越微弱。孩子们根本听不进关于“为什么整理房间能预防脑膜炎”的长篇道德说教；他们唯一能产生反应的是立竿见影的现实后果。说一次指令，然后立即用行动和后果来跟进支持。 - **肢体接触与坚定眼神（Touch, then talk）**：在向孩子发布指令或给予正面反馈前，先通过肢体接触获取他们的注意力——把手搭在他们的手臂、手部或肩膀上。接着直视孩子的眼睛，带着像“克林·伊斯威特（Clint Eastwood）”一样坚定利落的眼神，用简短干练的语言说清你的要求或赞赏。 - **高频检查与定闹钟**：养育 ADHD 患儿的父母应该随身设置定时器，每隔几分钟就响铃提醒自己去查看孩子所处的环境和状态。这不仅能有效防范意外身体伤害，更能让父母在危机爆发前及时介入，变“被动灭火”为“主动预防”。 - **增加外部后果的频次**：ADHD 患儿对滞后的内部奖惩极度迟钝，需要高频、具象的即时外部后果作为支撑。父母无需为此感到内疚或担心把孩子培养成市侩的功利主义者，“因为他骨子里早就已经是个小现实主义者了”。 - **切碎任务与 30% 规则**：既然孩子存在注意力时长缺陷，就绝不能强行拔高其注意力极限。父母和老师必须遵循“30% 规则”——将孩子的实际生理年龄缩减 30%，依此折算其真实的执行功能与注意力年龄。面对功课或考试，切忌将厚厚一叠任务一口气堆在他们面前，而要化整为零。例如，把 30 道数学题裁切成每页仅 5 道题的小片段，孩子做完 5 道便拿给家长，家长用剪刀裁下接下来的 5 道继续做，中间穿插短暂的休息。对于 ADHD 学生（即使是大学生）来说，将任务拆成短小模块并提供高频休息，其效果远远优于单纯在考试中延长答题时间。 ### [02:09:06](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=7746s) 破除“延长考试时间”的迷思与停表策略 ```mermaid flowchart TD accTitle: ADHD考试支持策略对比 accDescr: 对比传统延长考试时间策略与停表可中断策略的不同效果与机制。 subgraph Bad["传统策略：盲目额外时间 (Extra Time)"] direction TB B1["盲目增加30~60分钟"] --> B2["主观时间感如同糖浆般迟缓"] B2 --> B3["极度煎熬/坐立难安/弃考离场"] end subgraph Good["推荐策略：停表计时 (Time Off the Clock)"] direction TB G1["总时长与常人相同 (如60分钟)"] --> G2["秒表计时：随时可暂停"] G2 --> G3["站立、伸展、提问、呼吸"] G3 --> G4["恢复专注后重新按表继续"] end ``` 许多家长和学校在面对 ADHD 儿童的考试评估时，习惯照搬学习障碍（Learning Disabilities）的支持方案——要求“额外延长考试时间”（extra time）。对此，Russell Barkley 博士直截了当地指出，对一个完全没有时间感的人来说，盲目延长考试时间无异于“人间地狱”。Barkley 博士邀请在场听众回忆自己五岁时等待圣诞节到来的那个星期：“那种感觉就像糖浆在流淌一样缓慢而沉滞。对于 ADHD 患儿来说，这种度日如年的感觉就是他们的日常，而你居然还要在考试中多塞给他们一个小时！”结果往往是孩子再也坐不住，早就夺门而逃了。Barkley 博士毫不留情地讽刺道：“我特别喜欢‘延长考试时间’这个建议，因为它实在太愚蠢了。” 真正行之有效的替代方案被称为“停表计时”（Time Off the Clock）。其操作核心并不是增加总作答时长，而是改变时间的组织形式： - 孩子手中持有一个秒表，上面设定的总时长与普通学生完全一致（例如均为一个小时）。 - 启动秒表后孩子开始作答；只要孩子感到疲惫或分心，随时可以叫停秒表。 - 在秒表暂停期间，孩子可以站起来伸展身体、休息片刻、喝口水或向老师提问；调整完毕后，重新启动秒表继续答卷。 - 这种策略最终确实会消耗更多现实时间，但 Barkley 博士强调，耗时增加仅仅是该策略的副产品，而不是策略本身——“告诉别人他们有额外时间根本算不上是一种策略”。 - 目前，美国教育考试服务中心（Educational Testing Service, ETS）已在整个印第安纳州推广这一方案，旨在证明在应对限时选择题考试时，停表机制比注定失败的传统延时更具说服力。将工作切成小块、高频休息并借助外部计时器，任务才能真正完成。 ### [02:10:45](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=7845s) 主动式转换规划与行为监控卡 ```mermaid flowchart LR accTitle: 主动式活动转换四步法 accDescr: 展示在活动转换前父母应执行的四个前置关键步骤。 A["全面暂停现有活动<br/>(关电视/停下手头事)"] --> B["前置声明2-3条明确规则"] B --> C["明确奖惩兑现机制<br/>(筹码/积分/特权 vs 暂停/扣分)"] C --> D["任务中即时分发奖惩<br/>并在事后复盘自评"] ``` Barkley 博士提醒家长，不仅在监控孩子行踪时要主动，在活动之间的“场景转换”（transitions across activities）上更要采取主动预防策略。大部分家长和老师习惯做“反应式育儿”（reactive parenting）——各自忙着洗衣服或做晚饭，直到孩子闯祸失控了才冲过去像消防员一样到处灭火（reactive firefighting）。为了将问题减少 50%，每当家庭活动面临重大切换时（例如看电视转为写作业、准备进超市、去餐厅、下楼活动、去祖父母家或有朋友来访），家长必须立刻按下暂停键，执行严格的转换流程： 1. **全面暂停当下的动作**：关掉电视，让所有人停下来听指令。 2. **提前重申两到三条具体规则**：讲明接下来这项活动必须遵守的界限。 3. **明示激励与惩罚措施**：明确孩子能得到什么（如代币、积分、任天堂/Game Boy/Wii 的游戏时长等特权），以及违反规则会失去什么（扣除积分、取消特权或被罚暂停隔离）。 4. **过程即时强化与事后复盘**：奖惩必须分散在任务进行的过程中频繁兑现，绝不能拖到全部结束后才结账，否则孩子根本坚持不到最后；任务完成后，邀请孩子进行自我评估（“你觉得自己表现如何？我们下次怎么做能更好？”）。 当孩子离开父母视线时（例如在学校、童子军活动、少儿棒球联盟、足球队、冰球队、在朋友家玩、由保姆看管或与祖父母共度周末），家长应推行“行为监控卡”（Behavior Monitoring Card）： - 以学校为例，监控卡上方设有 1 到 5 分的评分标准。每节 45 分钟的课程结束时，任课老师都会当场给该时段的表现打分并签名（签名是为了防止孩子涂改伪造）。 - 评分直接对应奖惩：卡上用括号注明了获得的分数，若出现 4 分或 5 分这种糟糕评级，则对应扣减积分。 - 孩子放学回家后，父母与孩子一起核对卡片，加总正分、扣除负分，随后将净得分兑换进家里的代币系统或奖励看板中。 - 无论负责监督的是老师、教练、保姆还是祖父母，只要让现场成年人进行高频评估（每 15 分钟或每节课一次）并将记录带回家执行奖惩，即便父母不在场，也能通过极高的问责机制将行为问题降到最低。 ### [02:14:16](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=8056s) 药物治疗的必要性与中枢兴奋剂的发展 ```mermaid flowchart TD accTitle: ADHD治疗干预人群分布 accDescr: 说明ADHD患儿对行为干预与药物治疗的需求比例。 Total["ADHD 患儿群体"] --> GroupA["约 1/3 (30%)<br/>仅靠行为调整即有足够改善<br/>(其中部分用药仍可获益)"] Total --> GroupB["约 2/3 至 80%<br/>在人生某一阶段必须配合药物治疗<br/>(取决于严重程度与照顾者支持力度)"] ``` 尽管环境调整与行为干预至关重要，但 Barkley 博士强调，单凭这些手段往往不够：“只有三分之一的 ADHD 患儿对这些行为改变有足够充分的反应，从而无需使用药物；而即便是在这部分孩子中，许多人若配合药物治疗其实仍能进一步获益。”从临床经验来看，多达三分之二乃至 80% 的孩子在人生的某个阶段都必须接受药物治疗。这取决于照顾者的宽容与配合程度，以及孩子自身 ADHD 症状的严重程度。对于希望了解精神类药物的家长，Barkley 博士特别推荐了 Timothy Wilens 博士撰写的经典科普著作《Straight Talk About Psychiatric Medications for Children》（可通过 ADD Warehouse 或 Guilford Publications 购买）。 在药物的具体分类与历史方面，Barkley 博士梳理了核心脉络： - **中枢兴奋剂（Stimulants）**：目前本质上仅有两大类化合物——安非他命类（Amphetamines，始于 1936 年）与哌甲酯类（Methylphenidate，始于 1957 年）。它们是儿科学和精神病学领域中研究最透彻、使用历史最悠久的药物，其安全性和有效性拥有极其坚实的实证数据支撑。 - **给药系统（Delivery Systems）的革新**：中枢兴奋剂过去七八年间的重大突破并不在于新分子，而在于药物递送技术。传统的速释制剂药效仅能维持 3 到 4 小时，孩子一天必须服药两到三次，往往需要在学校由校医给药，带来诸多管理难题与社交尴尬。为此，制药公司研发了被称为“5P”的四种新型缓释/长效给药系统，实现了单次服药、全天平稳维持药效。 - **幼儿安全性研究**：前一年刚发表的一项针对学龄前 ADHD 患儿的最大规模兴奋剂安全性研究显示，此类药物低至两岁患儿使用时依然被证实安全有效。尽管学龄前儿童的药理反应稍弱于大龄儿童，但并没有出现未知的严重副作用，绝不存在致命风险，家长无须过度恐慌。 ### [02:17:02](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=8222s) 非兴奋剂药物的选择：托莫西汀与胍法辛 对于不适合或不能耐受中枢兴奋剂的患儿，现代精神医学提供了非兴奋剂（non-stimulant）替代方案： - **托莫西汀（Atomoxetine，商品名 Strattera / 择思达）**：美国于 2003 年批准上市，加拿大约一年后引进。托莫西汀不属于中枢兴奋剂，完全不存在药物滥用和成瘾风险。虽然其整体有效率略逊于传统的兴奋剂，但药效已非常接近。尤其是对于伴随抽动障碍（tics）、焦虑症、妥瑞氏综合征（Tourette's syndrome）、强迫症（OCD）或失眠等共病（comorbidities）的 ADHD 患儿，托莫西汀是极佳的替代药物，因为它不会加重这些共存的病症。 - **长效盐酸胍法辛（Guanfacine XR，商品名 Intuniv）**：预计将在当年（2009年）8 月在美国正式上市。该药同样不是兴奋剂，而是一种降血压类药物（antihypertensive drug）。胍法辛在临床上用于治疗 ADHD 儿童已有多年历史，对于合并妥瑞氏综合征、双相情感障碍（bipolar disorder）或具有极强攻击性与爆发性行为（explosive behavior）的孩子，这种降压类药物表现出了显著的情绪与冲动控制辅助疗效。 Barkley 博士在此总结道：“虽然托莫西汀在疗效上并非绝对超越兴奋剂，但对于特定共病患儿而言，它能提供不会恶化原有共存病症的平稳治疗效果。”同时，随着新型长效非兴奋剂药物（如 Intuniv）的问世，临床医生和家长在应对复杂共病的重度情绪行为失调时拥有了更为多样的武器库。 ### [02:18:01](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=8281s) 药物给药系统创新：“5P”模型与作用机制 在谈及胍法辛（Guanfacine，原商品名 Tenex）已由 Shire 公司研发出长效剂型并即将上市后，Russell Barkley 博士将话题转向 ADHD 药物给药系统的五大演进模式，即“5P”系统（Pill 普通药丸、Pump 泵式微胶囊、Pellet 缓释微丸、Patch 透皮贴剂、Pro-drug 前体药物）。 ```mermaid flowchart TD accTitle: ADHD 药物给药系统演进（5P系统） accDescr: 展示 ADHD 药物从传统口服药丸到微型液压泵、缓释微丸、透皮贴剂以及前体药物的五种递送方式及其特点。 subgraph Oral["口服吸收机制"] Pill["Pill 普通药丸<br/>(3-5 小时，如 Ritalin/Dexedrine)"] Pump["Pump 液压微泵<br/>(Concerta 约 8-12 小时，下午浓度更高)"] Pellet["Pellet 缓释微丸<br/>(Adderall XR 等，早晨见效好，可洒在食物上)"] end subgraph NonOral["非典型递送机制"] Patch["Patch 皮肤贴剂<br/>(Daytrana 经皮吸收，防滥用但有皮疹风险)"] Prodrug["Pro-drug 前体药物<br/>(Vyvanse 结合赖氨酸，体内酶解激活，防滥用)"] end Pill --> Pump Pill --> Pellet Pill --> Patch Pill --> Prodrug ``` 第一个“P”是传统药丸（Pill），即最早的利他林（Ritalin）和右旋安非他命（Dexedrine），药效仅能维持约 3 到 5 小时。为了克服频繁服药的难题，制药技术引入了微型液压泵（Pump）系统，其代表药物为专注达（Concerta）。Concerta 的胶囊外壳涂有一层粉状利他林，吞服后立即起效；胶囊顶端有一处极微小的激光打孔，内部则填充了两层不同剂量的哌甲酯泥状物（前半段为轻度剂量，下午释放的剂量翻倍）。胶囊进入体内后，水分以恒定速率进入上层腔室产生液压，如同挤牙膏一样，将利他林药液持续挤出，作用时间长达 10 到 12 小时，最终胶囊外壳随排泄物排出体外。 第三个“P”是时间释放微丸（Pellet）系统，广泛应用于 Adderall XR、Focalin XR、Ritalin LA 以及新型胍法辛缓释剂。其原理是将药物（如安非他命）制成不同微丸并包覆不同融化时间的涂层，有的立刻溶解，有的在数小时后逐渐溶解。Barkley 博士对比指出，泵式与微丸系统在全天的总体覆盖时间（约 8 到 10 小时）并无本质区别，但作用高峰的时段不同：“微丸系统在早晨问题最严重时效果更好；如果问题偏向下午或傍晚，微泵系统则更胜一筹。”此外，微丸系统的一大优势在于：若孩子无法吞咽胶囊，家长可以拆开胶囊将微丸直接洒在酸奶或苹果酱等食物上，完全不会改变其释放曲线。 第四个“P”是透皮贴剂（Patch），代表产品为 Daytrana（哌甲酯贴剂）。贴剂可贴在臀部、肩部或髋部，药物通过皮肤缓慢吸收，免去了吞服药物的烦恼。Barkley 博士打趣道，这种贴剂极难被滥用，因为“你不可能把贴片吸进鼻子里”。然而，贴剂也有局限性：约 15% 至 18% 的患者因对药物成分过敏而出现皮疹，无法耐受，但仍有 80% 至 84% 的人能够良好适应。 第五个“P”则是前体药物（Pro-drug），即 Vyvanse（赖氨酸安非他命）。它是历史上首个此类药物：安非他命分子与赖氨酸（Lysine）发生化学结合而被“锁住”，本身完全没有活性；只有吞入胃肠道并被血液中的特定酶切断赖氨酸后，安非他命才会释放并起效。正因如此，它成为首个真正无法通过注射或鼻吸滥用的安非他命制剂。相比同厂的 Adderall XR，Vyvanse 药效延长至约 12 小时，且起效和消退过程更加平缓柔和。 ### [02:22:54](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=8574s) 破除中枢兴奋剂的常见误区：攻击性、抽动症与所谓“过度用药” 针对公众与媒体对中枢神经兴奋剂的种种误解，Barkley 博士逐一进行了科学澄清。他强调，只要严格按处方口服，这类药物绝无成瘾性（除非被研磨后注射或经鼻吸入）。它们不会引发攻击行为，更不是科伦拜恩校园枪击事件等暴力的诱因；相反，它们在临床上能够显著降低患者的攻击性和反社会行为。同时，治疗剂量的兴奋剂不会诱发癫痫，除非一次性吞服整瓶药物，因此患有癫痫共病的儿童同样可以安全用药。 关于抽动障碍（Tics）和妥瑞氏综合征（Tourette's Syndrome），Barkley 博士解释道，药物本身不会凭空制造抽动症状，仅在约 30% 本身具有易感体质的患儿身上可能暂时放大或加重抽动，而在其余 70% 的抽动共病儿童中并无恶化倾向。即使出现加重，这种现象也是完全可逆的——一旦停药，抽动在短短一周内就会恢复到基线水平。 谈及北美社会是否对 ADHD 儿童“过度用药”的指责，Barkley 博士给出了坚决的否定回答：“我们在北美是否对 ADHD 儿童用药过量？绝对没有。”他列举了一组具有说服力的数据： - **儿童患病率与治疗率落差**：全人群中 ADHD 患病率约为 7.5%，但目前实际接受药物治疗的儿童比例仅在 4% 到 5% 之间，这意味着至少有整整三分之一的确诊儿童被漏诊或得不到应有治疗。 - **成人治疗严重缺位**：在所有患有 ADHD 的成年人中，高达 90% 从未接受过任何治疗。 - **公共卫生核心矛盾**：美国卫生局局长（Surgeon General）曾明确指出，当前的核心问题并非过度治疗，而是大量患者缺乏获取专业医疗的渠道。 ### [02:24:27](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=8667s) 媒体偏见与误导：成瘾风险的真相及对学业的长期影响 Barkley 博士随后公开抨击了加拿大广播公司（CBC）旗下的调查报道节目《Marketplace》。该节目曾大肆宣扬兴奋剂会导致儿童在成年后对可卡因、尼古丁等药物成瘾。Barkley 博士指出，该节目的结论仅建立在旧金山研究员 Nadine Lambert 的单一项严重缺陷的研究之上——该研究甚至未对“品行障碍”（Conduct Disorder，导致成瘾的核心中介变量）进行变量控制。 当研究对品行障碍进行统计控制后，儿童期服用兴奋剂与成年后药物滥用之间毫无关联。Barkley 博士指出，包括他本人的长期追踪研究在内，已有 17 项严谨的研究证实了这一结论，然而电视媒体为了追逐轰动效应，彻底忽视了 17 比 1 的压倒性科学共识。对于现代电视新闻的生态，Barkley 博士尖锐地评价道：“因为我们现在都知道，电视新闻报道是一种娱乐形式，而不是一种提供信息的渠道。” 针对兴奋剂能否直接提升“学习成绩（Academic Achievement）”的疑问，Barkley 博士作出了客观剖析： | 评估维度 | 短期效果（用药初期） | 长期效果（坚持用药 2 年以上） | |:--- |:--- |:--- | | **知识储备** | 无法直接注入知识（“药丸里没有知识”） | 累积效应显现，能够学习并掌握更多知识 | | **学习能力表现** | 提升作业生产力（Productivity）与完成量 | 技能水平出现可量化的实质性提高（Uptick） | | **核心机制** | 让大脑处于“可接受学习的状态（Available for learning）” | 长期保持受教状态，逐步弥补学业落后 | 在解答完兴奋剂的作用后，Barkley 博士提到了非中枢兴奋剂托莫西汀（Strattera）。对于同时伴有焦虑症、抽动症、强迫症（OCD）以及失眠或睡眠障碍的 ADHD 患儿，非兴奋剂药物展现出了极为稳定且适配的临床治疗优势。最后，他提醒广大家长，在选择干预方案时必须保持理性，果断避开那些已经被科学证实无效、或成功概率极低的伪科学疗法。 ### [02:27:20](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=8840s) 伪科学与无效疗法辨析：饮食疗法与鱼油迷思 Dr. Russell Barkley 首先向台下听众致歉，解释讲义上的内容可能与幻灯片有些微出入。因为他昨天重新调整了幻灯片的逻辑结构，力求呈现最新、最合理的教学脉络，不过现场观众依然能获得“99%的核心内容”。随后，他直截了当地列出家长必须避开的各种疗法陷阱。他指出，这些干预手段要么荒谬到科学界根本不屑于去研究，要么就是早已被严格的科学试验证明毫无效果。 以广为流传的饮食干预为例，去除食物中的人工色素、香精和防腐剂等“排除饮食法”（Elimination Diets，如著名的 Feingold 饮食法），实际上对极少数儿童有效。数据显示，大约每20名 ADHD 患儿中仅有1人能从中受益，且主要是5岁及以下的幼童。Dr. Barkley 强调，绝大多数患儿对这些物质并无不良反应，将饮食限制视作普适性解药完全是误导。同样，试图通过往饮食中添加营养补充剂来治疗 ADHD 更是徒劳无功，无论是抗氧化剂、大剂量维生素还是备受推崇的鱼油（Omega-3），目前均无确凿疗效。瑞典哥德堡大学（Gothenburg）研究团队近期发表了一项控制极为严谨的鱼油临床试验，结果令人清醒：仅有25%的孩子出现反应，且主要集中于伴有迟缓认知节奏（SCT）的注意力不集中型患儿身上，整体改善幅度极其微弱，以至于该研究团队最终也建议不要将其作为治疗手段。正如 Dr. Barkley 所断言：“没有任何东西可以通过吃进肚子里来治愈这种障碍。” 在讲解期间，会场广播突然插入一条紧急寻人通知（呼叫 Daryl McMichael 立即接听电话），Dr. Barkley 幽默而耐心地化解了这一插曲，随后继续深入剖析其他无效干预。 - **饮食排除法效果有限**：仅约 5%（1/20）的患儿（主要是5岁及以下幼童）对人工色素和添加剂有不良反应，绝不能将其作为常规疗法。 - **营养补剂证据匮乏**：抗氧化剂、大剂量复合维生素、鱼油等均未展现出确切疗效；任何宣称鱼油有奇效的报告都源自缺乏严格对照的研究。 --- ### [02:29:18](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=8958s) 无效的身体与心理干预：感觉统合、颅骨按摩与游戏疗法 在谈到学校环境中泛滥的非药物疗法时，Dr. Barkley 情绪激动地指责了目前在美国学区增长最快、却早已被证伪的疗法——感觉统合训练（Sensory Integration Training）。许多职业治疗师（OT）接受了感统评估与技术的额外培训，向家长推销这套练习。然而，无论针对学习障碍（LD）还是 ADHD，大量严谨研究甚至感统领域的专业期刊自身发表的荟萃分析都明确显示，感觉统合训练毫无疗效。“感觉统合已被彻底证伪，”Dr. Barkley 慨叹道，但现实中仍有大量孩子被盲目送去接受这种毫无意义的训练。 至于脊骨神经医界宣称通过“颅骨按摩”或所谓“神经组织架构训练”（Neurologic Organization Training）来治疗 ADHD，Dr. Barkley 则直接将其定性为荒谬之谈：“按摩头皮到底凭什么能对 ADHD 起到任何治疗作用？”他直言这种说法过于荒唐，根本不值得浪费时间探讨。此外，许多家长寄予厚望的传统游戏疗法（Play Therapy）同样被证实对 ADHD 的核心症状无效。Dr. Barkley 解释道，游戏疗法旨在帮助儿童排解情绪与应对压力，但 ADHD 的病因根本不是环境压力引发的心因性障碍；虽然游戏疗法对于患有焦虑症、创伤后应激障碍（PTSD）或抑郁症的儿童有所助益，但它对改善 ADHD 的注意力和执行功能障碍起不到任何实质作用。 --- ### [02:30:35](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=9035s) 自我控制训练与社交技能训练的真相 谈及心理学界曾经寄予厚望的干预手段，Dr. Barkley 提到了自我控制训练（Self-Control Training）——即训练孩子在执行任务时大声自言自语、进行自我言语指导的技术。早年学界对其抱有极高期望，但最终临床试验全部宣告失败。不过，研究者在这堆“废墟”中淘出了一颗钻石：言语自我指导的有效性与年龄高度相关。年龄越小，这种方法越不起作用；但到了青春期晚期至成年期，这种认知策略便开始展现价值，**前提是患者必须处于药物治疗的保护之下**。Dr. Barkley 强调，认知行为疗法只能作为药物治疗的补充，而绝不能取代药物。他推荐了哈佛医学院 Steve Safren 编写的成人 ADHD 认知疗法手册，以及宾夕法尼亚大学 Russell Ramsay 的著作，供有需要的成人患者参考。 针对社交技能训练（Social Skills Training），Dr. Barkley 更是提出了颠覆常规诊疗模式的警告。他指出，把孩子关在诊所里、和一群他这辈子再也不会见面的同龄人练习社交，完全是浪费时间与金钱。社交技能培训若想发挥作用，必须遵循“80/20 法则”并直接转移到真实场景中： ```mermaid flowchart TD accTitle: 社交技能训练的有效实施比例与场景 accDescr: 展示80%表现点干预与20%技能训练在真实环境中的配比结构 subgraph 真实环境 ["干预必须发生在真实环境（学校、产生冲突的同伴群体）"] A["执行表现点干预（80%）<br>包括：现场实时提示、同伴互动实操、即时奖励强化"] B["脱离情境的技巧传授（20%）<br>仅占极少比例的规则与技能讲解"] end ``` Dr. Barkley 告诫在场的家长与专业人士：“如果你们遵循这种平衡，把它放到真正重要的地方去执行，它或许还有一线成功的机会。如果你在诊所里和那些他余生再也不会见面的孩子一起做训练，它根本毫无用处。” - **自我控制训练的年龄门槛**：儿童阶段无效；仅在晚期青春期与成年期，且在药物辅助的前提下，认知行为策略才能发挥补充作用。 - **社交训练的 80/20 铁律**：20% 的精力用于基础技巧教学，80% 的精力必须放在真实“表现点”（Point of Performance）进行提示、实战演练与即时奖惩。 --- ### [02:32:00](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=9120s) 家长自身的 ADHD：识别与干预的必要性 Dr. Barkley 指出，在抚养 ADHD 患儿的家庭中，有高达 25% 至 35% 的父母自身也患有未被诊断或治疗的 ADHD。在过去，专业人员往往忽视这一因素，不询问也不在乎，但如今的研究表明，家长的 ADHD 是决定家庭干预成败的关键变量。英属哥伦比亚大学的 Charlotte Johnston 与马里兰大学的 Andrea Chronis 等学者针对患病家长的育儿行为展开了深入研究，揭示出令人担忧的连锁反应：患有 ADHD 的父母往往表现出更高的冲动性、更高的负面情绪表达（Expressed Emotion）、更频繁严苛的惩罚，以及对孩子日常活动的监控能力显著下降。 这种教养环境的失控，会直接成倍推高患儿继发对立违抗障碍（ODD）的风险。Dr. Barkley 严肃指出，如果父母自身的执行功能处于瘫痪状态，他们就不可能稳定执行复杂的行为矫正方案。因此，“父母的 ADHD 必须被筛查并得到妥善管理，而不仅仅是治疗孩子的 ADHD。”不仅如此，临床研究已证实，如果父母自身患有未经治疗的 ADHD，这是预测行为家长培训（Behavioral Parent Training, BPT）以失败告终的最强预测指标。 --- ### [02:33:07](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=9187s) 宽恕的艺术：原谅自己与摆脱工程师心态 在演讲进入尾声之际，Dr. Barkley 引用了著名特教专家 Leo Buscaglia 约三十年前写给自闭症等特殊儿童家庭的著作，向在座的所有父母提出了最核心的心灵告诫：**学会践行宽恕**。Buscaglia 提出，特殊需要儿童的家庭必须掌握四种宽恕，而首当其冲的便是“原谅自己的过失”。抚养普通孩子尚且难免犯错，抚养 ADHD 患儿时父母更容易情绪失控，因为患儿极度擅长“踩中家长的雷区”，诱发家长做出事后后悔不已的过激反应。 Dr. Barkley 引用发展心理学家 Judith Rich Harris 的群体社会化理论半开玩笑地安慰家长：“如果 Judith Harris 是对的，你其实没那么重要。”他劝诫家长放下虚妄的掌控欲，正如哲学家与教育家所强调的，核心问题绝不在于你今天是否犯了错，而在于明天你打算如何避免重蹈覆辙。 为了帮助家长建立自我宽恕的心态，Dr. Barkley 再次重申了“牧羊人与工程师”的隐喻： | 育儿范式 | 工程师思维（应摒弃） | 牧羊人思维（应倡导） | |:--- |:--- |:--- | | **核心假设** | 将孩子视为一团黏土，认为自己拥有全能的塑造权 | 将孩子视为拥有独特天资与基因蓝图的独立生命 | | **关注焦点** | 孩子的缺陷、偏差、未能达标的表现 | 孩子的独特性，去享受、珍视和陪伴其成长 | | **心理后果** | 承担巨大的挫败感、焦虑，容易陷入自责与愤怒 | 卸下不切实际的重担，学会欣赏当下，容忍失误 | Dr. Barkley 动情地说道：“正如 Buscaglia 所说，真正重要的是：你下次是否努力去做好？重点不是你有没有犯错，而是你明天要做些什么来确保它不再发生。” --- ### [02:34:44](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=9284s) 宽恕孩子：化解怨恨与两项疗愈仪式 宽恕的第二个维度是原谅孩子，而这比原谅自己艰难得多。ADHD 患儿每天24小时不间断地产生问题行为，家长不得不时刻充当他们外化的“额叶”，这种漫长且高负荷的代理调控极易让人筋疲力尽。长此以往，许多父母内心会滋生出怨恨情绪，暗自期盼自己能拥有一个更听话、更“正常”的孩子。Dr. Barkley 极为沉重地警告：“这种认为孩子是故意捣蛋的想法，正是怨恨的根源之一。而这种怨恨，距离合理化虐待儿童仅有一步之遥。” 为了化解心中的怨气并重建亲子联结，Dr. Barkley 分享了两位家长传授给他的两项极具操作性的疗愈仪式： 1. **写下并焚烧负面情绪（驱魔仪式）**：在一天结束、吃完晚饭后，倒上一杯咖啡或干邑白兰地，拿出一张白纸，巨细靡遗地写下今天孩子惹出的所有麻烦和冲突，将内心的“心魔”完全宣泄在纸面上。随后，走到水槽前，划一根火柴将这张纸彻底烧成灰烬。“这就像一场驱魔仪式，心魔已经消散，今天已经翻篇，彻底放手吧。” 2. **静坐注视熟睡的孩子（重塑天真视野）**：在孩子入睡后，走进他的卧室，像练习瑜伽一样盘腿静坐在地板上，伴随着平缓的呼吸，静静注视着沉睡中的孩子。Dr. Barkley 深情地表示：“世界上再也没有什么比看着一个熟睡的幼童更纯真无邪的景象了。如果这都无法给你的电池重新充电、无法恢复你审视孩子的平衡视角，我真不知道还有什么能做到了。” 通过这两个具象化的练习，家长得以在日复一日的疲惫与拉扯中抽离出来，重温对孩子的无条件接纳与爱。正如 Dr. Barkley 所强调的：“你必须擅长原谅这些孩子犯下的错误，因为他们确实会犯很多错误。” ### [02:36:43](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=9403s) 原谅配偶与面对公众的误解 在一天结束之际，父母需要学会放下白天的挫败。Dr. Russell Barkley 幽默地提到，哪怕是“在看着孩子入睡时喝一杯红酒”，只要能帮助自己释怀并寄希望于明天做得更好，这就足够了。他强调，最重要的永远是明天努力做得更好，而不是今天犯了多少错误；同样的宽容态度也必须施予配偶或伴侣，不要因为对方管教孩子的方式与自己的预期略有出入就大动肝火。 演讲的核心之一是增进对多动症（ADHD）的科学认知，但这也伴随着一个残酷的现实：公众对 ADHD 几乎一无所知，充满偏见。Barkley 提醒家长们必须学会原谅那些在沃尔玛（Walmart）或澳美客牛排馆（Outback Steakhouse）投来鄙夷目光的路人。他分享了自己亲戚的遭遇：他的嫂子育有一个患有 ADHD 的儿子（即他的侄子 Dan）。有一次在 Target 超市，一位年长女性径直走过来指责她：“管好你的孩子！这都是你的错。要是你们这些年轻父母能拿出魄力、多给孩子立规矩，我们就不会有这些麻烦了。”该妇人甚至一路尾随她到停车场，趴在车窗外不断叫骂，直到车门锁上，他的嫂子在车内委屈得泣不成声。 面对这种普遍的社会指责，Barkley 建议家长练就一副“厚脸皮”。他半开玩笑地提出一种认知疗法技巧：当路人投来恶毒目光时，家长可以在脑子里默念反击的话，但千万别当面说出来。关于社会的无知与误解，Dr. Russell Barkley 总结道：“But you better get good at forgiving the public they're misunderstanding. Cuz boy, do they misunderstand this disorder.” 随后，Barkley 宣布 30 条核心要点讲解完毕，并开放现场问答。 - 关键认知调整：对伴侣多一份宽容，教育理念有细微分歧很正常，避免内耗。 - 公众误区：普遍将神经发育障碍导致的自控力缺陷归咎于“家教不严”或“父母失职”。 - 应对原则：保持冷处理，不要让路人的无知摧毁自己的生活节奏。 --- ### [02:39:22](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=9562s) 问答：30%延缓法则在服药后是否依然适用？ 现场有观众提问：“如果孩子正在服药，‘30%执行功能发育迟缓法则’（30% rule）是否依然适用？” Barkley 明确回答：在药效发挥期间，该法则不适用。临床数据显示，药物在 55% 至 65% 的患儿身上能够产生“正常化”（normalization）的疗效，这相当于超过一半乃至近三分之二的比例。在药效维持的时间窗口内，这 30% 的发育差距会被完全抹平。然而，药物的作用是暂时的，随着药物在体内代谢，到晚上 8:00 药效退去，孩子又会回到落后同龄人 30% 的状态。 对于其余患儿，药物反应呈现出不同梯度： - 约 30% 的患儿在服药后差距缩小（improvement），但未能完全达到同龄人水平（normalization），仍需要环境脚手架与其他支持措施介入。 - 约 10% 至 15% 的患儿对市面上的任何一种药物均无反应。 - 对于完全无反应的群体，家长和学校必须全盘接受这 30% 的执行功能落后，并在日常生活中尽可能做好全方位的环境适应与代偿。 ```mermaid flowchart TD accTitle: 药物对 ADHD 患儿 30% 执行功能差距的改善比例 accDescr: 流程图展示了服药后患儿在正常化、部分改善和无反应三个不同区间的分布情况。 A["ADHD 患儿服药治疗"] --> B["55% - 65% 患儿"] A --> C["约 30% 患儿"] A --> D["10% - 15% 患儿"] subgraph Normalization["完全正常化区间"] B --> B1["药效期内差距归零"] B1 --> B2["晚间药效退去后回到落后 30%"] end subgraph Improvement["部分改善区间"] C --> C1["执行功能差距缩小"] C1 --> C2["需额外行为与环境代偿"] end subgraph NonResponders["无反应区间"] D --> D1["药物无显著效果"] D1 --> D2["必须完全依赖环境支持容纳 30% 差距"] end ``` --- ### [02:40:28](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=9628s) 问答：如何应对邻居评价并帮助孩子建立友谊？ 有家长提问如何处理与邻里或其他孩子家长的关系。Barkley 指出，没有放之四海而皆准的单一方法。现实中总有一些邻居或家长对任何解释都无动于衷，甚至排斥 ADHD 患儿；面对这种家庭，最好的策略是让孩子远离那个环境，寻找新的玩伴，避免孩子承受负面言语。 但大多数家长是讲理的。Barkley 推荐“真诚为上策”（honesty is the best policy）：家长可以从他的个人网站或 CHADD（Children and Adults with Attention-Deficit/Hyperactivity Disorder）官网上下载两到三页的科普单页，邀请邻居喝杯咖啡，主动说明孩子的诊断、症状表现以及家庭正在采取的干预措施。这能消除邻居认为孩子“故意捣蛋”或“父母失职”的误解。如果交流后发现对方依然冷漠且不愿理解，就绝不能让孩子在对方的监管或家中玩耍，但可以反过来邀请对方的孩子到自己家里来。 为解决 ADHD 孩子朋友少的问题，Barkley 给出了一个极为现实的建议：“把你的家打造成整条街上最好玩的地方。”他直言不讳地指出这虽然是“贿赂”，但极为有效： - 院子里要有最好玩的玩具，屋里备好最新款的视频游戏机（如任天堂 Wii）。 - 成为一个慷慨款待客人的家长：任何小孩进门，立刻递上软糖冰棍（fudge popsicle）、奥利奥饼干和牛奶。 - 营造一个即便你的孩子不在、其他孩子也极度渴望前来的乐园环境。 针对同伴交往的客观规律，Dr. Russell Barkley 强调：“You can't make other children like your child. That is not possible to do. You can only make them more likable or make the environment in which your child exists more likable and hopefully some of that sticks.” 孩子拥有自主选择朋友的权利，家长无法强求，但优越友善的环境能让其他孩子对患儿的不成熟行为产生更多包容。 --- ### [02:43:45](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=9825s) 问答：Cogmed 等工作记忆训练真的有效吗？ 针对市场上涌现的基于神经心理学理论（特别是工作记忆受损理论）的训练工具，Barkley 详细分析了由瑞典科学家 Torkel Klingberg 开发的著名程序 Cogmed。该程序通过让孩子每天进行约 45 分钟的前向/后向数字广度及空间记忆练习来训练工作记忆。由于训练过程极其枯燥乏味，头一两天过后孩子就会厌烦，因此必须建立一套严格的代币奖励机制，且整套程序收费高达数千美元。 Barkley 曾亲自走访瑞典并审查过 Klingberg 实验室的数据。他证实该训练确实能带来工作记忆的暂时提升，并随之带来多动症症状的短暂缓解。然而，Klingberg 自己的研究也显示，经过 3 到 6 个月的密集训练，效果最多只能维持大约 3 个月，随后就必须重新开始训练。Barkley 形象地将其比作举重运动员练肌肉：“我可以通过锻炼练出发达的二头肌，但只要我停止锻炼一个月，二头肌就会因为缺乏刺激而萎缩。”脑力训练同样如此，它并非永久性的生理重塑。 此外，由于 Klingberg 从销售中提取版税，存在利益关联，目前美国有五所大学、加拿大至少有一所大学正在进行独立重复实验。Barkley 指出，即便研究结果能被完全复现，其本质也只是一种需要一年内反复重启的“暂时性脑力体操”。对于想要尝试此类训练的家庭，Barkley 提出了一个更划算的选择： - 无需花费数千美元购买 Cogmed。 - 直接购买一台售价仅为其十分之一的任天堂 DS（Nintendo DS）主机以及《脑力达人》（Brain Age）软件。 - 该游戏不仅涵盖了 Cogmed 的全部工作记忆训练项目，还包含至少 6 种其他额叶执行功能训练任务，趣味性更强，性价比高出十倍。 ### [02:46:14](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=9974s) 大脑训练网站与执行功能训练工具的现实评估 对于那些不想花费几百美元购买任天堂 DS 掌机及配套软件的家庭，罗素·巴克利博士（Dr. Russell Barkley）建议翻阅《科学美国人》（Scientific American）旗下的一本大众科学期刊——《科学美国人：心智》（Scientific American Mind）。该杂志近期刊登了一篇针对互联网上所有执行功能训练网站的系统综述。这些网站有的免费，大多数则按月收取大约 9 到 10 美元的订阅费，里面集成了各类软件、认知训练小游戏以及成败表现追踪系统。任天堂或 Cogmed 所具备的训练功能，绝大多数都能通过这些网页平台实现，而无需购买专门的硬件设备。 在评估中，任天堂掌机展现出了独特优势：它是目前唯一的便携式系统，孩子可以随身携带，甚至在车里等待少棒联盟比赛开场时也能掏出来练习。至于备受推崇的 Cogmed 等系统，巴克利博士提醒家长保持审慎态度，务必等待更多科研证据出炉，以明确它们是否真的能成为有效的应对辅助手段。正如他明确强调的那样：“这只是一种应对工具，绝非治愈手段，根本不可能彻底治愈。”这些训练并不能从根源上消除 ADHD。 - 《科学美国人：心智》对主流大脑训练网站进行了评测，指出大多数平台的月费约为 9 至 10 美元。 - 网页训练工具包含认知游戏、软件模块及成败轨迹记录，功能与专用设备相当。 - 任天堂系统的主要优势在于便携性，适合碎片化时间训练。 - 认知训练与执行功能程序仅能作为日常应对工具（coping tool），绝非根治 ADHD 的灵丹妙药。 --- ### [02:47:46](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=10066s) ADHD 与双相情感障碍之间的单向单行道关系 谈及 ADHD 与双相情感障碍（Bipolar Disorder）之间的联系，巴克利博士明确指出这完全是一条“单向街”（one-way street）。单纯患有 ADHD 的儿童，其罹患双相情感障碍的风险并未超出普通人群的基线水平。无论是巴克利博士本人的长期追踪研究，还是来自加拿大、纽约、爱荷华、瑞典或澳大利亚的纵向研究，均一致证实 ADHD 儿童的双相患病风险仅为 2% 至 4%，与大众患病率完全吻合。如果一个孩子起初被确诊为单纯的 ADHD，他们大概率会一直维持 ADHD 的状态，未来发展出双相情感障碍的概率极其微小；唯一的例外是家族中有明确的双相病史，此时遗传风险会导致其发病率剧增八倍。 真正的关联方向是从双相情感障碍走向 ADHD。如果一个孩子在幼年期就早发双相情感障碍，他们同时伴随 ADHD 的概率高达 80% 至 97%。这种高共病率正是导致临床和公众混淆的根源：人们看到几乎所有幼年发病的双相儿童都伴随 ADHD，便错误地反推认为 ADHD 是导致双相情感障碍的巨大危险因素，而事实恰恰相反。此外，这种共病风险与双相情感障碍的发病年龄紧密相关：青少年期发病的双相患者伴发 ADHD 的比例降至 40% 到 45%，而成年期（双相最典型的发病期）发病者伴发 ADHD 的比例仅为 20% 到 25%。巴克利博士总结道：“因此请注意，是早发型双相情感障碍带来了伴随 ADHD 的高风险，而不是反过来。” ```mermaid flowchart TD accTitle: 双相情感障碍发病年龄与共病 ADHD 概率 accDescr: 展示不同发病时期的双相情感障碍患者伴随患有 ADHD 的风险比例 subgraph BipolarToADHD["双相情感障碍 -> 伴随 ADHD 风险"] A["幼年期发病 (Childhood-onset)"] -->|"80% - 97% 极高风险"| X["共病 ADHD"] B["青少年期发病 (Adolescence-onset)"] -->|"40% - 45% 中等风险"| X C["成年期发病 (Adult-onset / 典型)"] -->|"20% - 25% 较低风险"| X end subgraph ADHDToBipolar["ADHD -> 双相情感障碍风险"] D["单纯 ADHD 儿童"] -->|"仅 2% - 4%（等于普通人群基线）"| Y["发展为双相情感障碍"] E["ADHD 伴家族双相病史"] -->|"风险激增 8 倍"| Y end ``` - 单纯 ADHD 儿童患双相情感障碍的风险仅为 2% 至 4%，与普通人群完全一致。 - 具有双相家族史的儿童，罹患双相情感障碍的风险较常人增加 8 倍。 - 儿童期起病的双相患者中，共病 ADHD 的概率高达 80% 至 97%，且 ADHD 通常是最早显现的症状。 - 青少年起病的双相患者共病 ADHD 的概率为 40% 至 45%；成年起病者仅为 20% 至 25%。 --- ### [02:49:29](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=10169s) 早发型儿童双相情感障碍的严峻临床现实 若双相情感障碍在儿童期就早早发作，它将成为儿科精神医学中最为严峻的疾病之一，其破坏性仅次于婴儿期孤独症或精神分裂症。这类患儿极难管理，通常必须依赖多种药物联合治疗（多药疗法，polypharmacy）来控制病情。患儿不仅表现出极端的破坏性，而且极易出现暴力行为，在男童中尤为显著。为了确保人身安全并重新调整精神药理方案，患儿往往需要定期住院治疗。 巴克利博士深入探讨了治疗早发双相的艰难之处。用于治疗双相情感障碍的许多药物，其副作用远比常规 ADHD 兴奋剂药物严重得多；让孩子入院观察，很大一部分原因就是在滴定药物剂量的过程中严密监测严重不良反应。更令人揪心的是，当这些双相患儿步入青春期后，其自杀风险和物质滥用风险会出现爆发式剧增。巴克利博士神情凝重地感慨道：“这不是一种轻松好应付的疾病。大约有 2% 到 3% 的儿童患有双相情感障碍，病情严重且通常终身伴随，往往需要多种药物联用和定期住院，因此现状不容乐观。”不过值得宽慰的是，ADHD 本身并不会诱发双相情感障碍，绝大多数 ADHD 儿童永远不会面临这一厄运。 - 儿童期发病的双相情感障碍是除孤独症和精神分裂症外最严重的小儿精神疾患之一。 - 患儿常表现出严重的攻击与暴力倾向，男童发生率更高。 - 治疗通常需采用多药疗法（polypharmacy），药物毒副作用显著高于 ADHD 兴奋剂。 - 定期住院常用于确保安全及在严密监护下进行药物剂量滴定（titration）。 - 进入青春期后，双相患儿的自杀率和物质滥用（吸毒/酗酒）风险显著激增。 --- ### [02:50:54](https://www.youtube.com/watch?v=SCAGc-rkIfo&t=10254s) 400 余项严谨研究证伪安慰剂效应：药物的真实疗效 在解答关于药物疗效是否仅为“心理安慰剂效应”的质疑时，巴克利博士引用了海量的循证医学证据。针对治疗 ADHD 的中枢兴奋剂类药物，医学界目前已发表了 400 多项严格设计的研究；而针对托莫西汀（Atomoxetine）等非兴奋剂药物，同样存在大量的实证数据。所有这些权威研究全部采用了双盲、随机、安慰剂对照（placebo-controlled）的标准流程。 数据揭示了无可辩驳的事实：在绝大多数临床试验中，安慰剂组的有效反应率仅在 10% 到 35% 之间；而服用活性药物（active medication）的治疗组，有效反应率则高达 55% 到 92%，平均有效率稳定在 75% 左右。这一有效率整整是安慰剂的两倍以上。巴克利博士斩截有力地下结论道：“因此在这一点上，我们可以从这些随机安慰剂对照研究中确信，药物具有真正的疗效，而不仅仅是安慰剂效应所暗示的心理暗示作用。”虽然治疗中可能存在微弱的安慰剂成分，但绝大部分临床改善无疑是活性药物成分发挥的实际生物学效用。 - 评估兴奋剂治疗 ADHD 疗效的双盲随机安慰剂对照研究已超过 400 项。 - 对照试验中安慰剂的平均有效反应率处于 10% 至 35% 之间。 - 活性药物治疗组的有效反应率达 55% 至 92%，平均响应率约为 75%（相当于安慰剂的两倍以上）。 - 大规模循证医学数据证明，药物疗效绝非出于心理暗示或单纯的安慰剂效应，而是药理学活性成分的真实作用。 ## Video description Dr. Russell Barkely discusses ideas for parents of children with ADHD [Source](https://www.youtube.com/watch?v=SCAGc-rkIfo)

[16:19] Dr. Russell Barkley: ADHD is a failure to direct behavior forward in time. [45:14] Dr. Russell Barkley: SCT is an accuracy disorder, ADHD is a productivity disorder. [113:19] Dr. Russell Barkley: ADHD predisposes to no gift, but you do have other gifts and other talents at which you are good at. [83:21] Dr. Russell Barkley: A prosthesis is an artificial means of reducing the disabling consequences of your disorder. It is not to train you up into anything. [86:04] Dr. Russell Barkley: We don't manage ADHD to get rid of it. We manage it so that you don't experience those more heinous consequences. [7:26] Dr. Russell Barkley: You cannot be impulsive in your behavior and not be impulsive in your emotions. That is impossible because they are a unity. [11:38] Dr. Russell Barkley: The single best predictor of marital problems in the adult with ADHD is not distractibility. It is emotion. [121:34] Dr. Russell Barkley: So, I would rather that you stop thinking yourself as an engineer and step back and say, ‘I am a shepherd to a unique individual.

[0:13] Uh when Heidi asked me to come up uh to [0:15] speak to you at an invitation by the way [0:18] for which I'm grateful and and honored. [0:21] The I thought what am I going to say to [0:24] what is largely I believe a group of [0:26] parents and loved ones of people with [0:28] ADHD and and so she wanted me to do [0:31] something a little new and a little [0:32] different and I sat down and I said, [0:33] "You know, [0:35] what ideas would I want any family that [0:37] we had seen in our clinic [0:40] to understand by the time we had [0:42] finished working with that family? By [0:44] the time we'd finished the evaluation [0:46] and the counseling of that family, what [0:48] what would be the 30 take-home ideas? I [0:51] tried to reduce it to 10 by the way, but [0:53] that's just not possible. [0:55] And 30 was even a bit of a struggle. [0:57] There's another 30 I left out, but I I [0:59] think of these as sort of the touchstone [1:01] ideas that a family needs to understand [1:05] if they really are going to appreciate [1:07] that both the nature of this disorder in [1:08] a child and what it means for the [1:12] raising and management of that child [1:14] successfully. [1:16] So, we're going to have some fun with [1:17] this because I've not done this [1:19] presentation in this way ever before [1:22] and you may advise me never to do it [1:23] again. It's a [1:25] We'll see. [1:27] Obviously, the first idea is to know the [1:29] disorder and we begin at a very [1:31] elementary stage of this disorder. This [1:34] is a developmental disability. [1:37] That is the first thing you need to [1:38] understand. A disability of what? There [1:40] are two psychological traits that are [1:43] not developing in this child on time. [1:47] So, let's clarify that. A developmental [1:49] disability means that you are showing [1:51] age-inappropriate behavior. It doesn't [1:54] mean that your behavior is pathological. [1:57] It just means it's not appropriate for [1:59] your age. So, understand one thing. ADHD [2:03] is different from normal [2:04] in a quantitative way, not a qualitative [2:07] way. [2:08] Developmental disorders differ [2:11] from psychopathologies. [2:13] A psychopathology is a gross aberration [2:16] in your behavior that we can recognize [2:19] at any age. If you are bipolar, if you [2:22] are schizophrenic, if you have major [2:24] depression, we don't need to adjust the [2:27] criteria for your age [2:30] because those are grossly abnormal [2:32] conditions. Autism would be another one. [2:35] Those are not developmental [2:37] disabilities. [2:38] A developmental disability is a delay in [2:41] the rate of a normal trait. [2:44] What distinguishes this child [2:47] from other children who don't have the [2:49] disorder [2:50] is the degree of the delay. [2:53] They will go through the same stages [2:55] that others would go through in normal [2:57] development, but not at the same time. [3:01] And when these traits reach their [3:03] ultimate maturity, which by the way is [3:06] your early 30s, [3:08] the person with ADHD will be leveling [3:11] off [3:12] at a degree well behind that of where [3:16] the general population has leveled off [3:18] in that trait. [3:20] So, delay does not mean lag. It doesn't [3:23] mean temporary. [3:25] This is a chronic lag in the development [3:29] of these traits. But, the important [3:31] thing is that the difference between [3:32] this child and other children is [3:34] quantitative. It is like someone sitting [3:37] next to you who is shorter or taller. It [3:40] is like someone who is more athletic or [3:43] less athletic. These are not qualitative [3:45] differences. They're quantitative. [3:48] So, that is what separates your child [3:50] from others. The degree of the delay is [3:53] the distinction. I say this because so [3:55] many trade books written for parents [3:57] have argued that ADHD is a qualitatively [4:00] different human. [4:02] Your child is a little hunter and he has [4:05] to go to school with farmers. [4:07] Your child has a gift that other [4:10] children do not have. This is nonsense. [4:13] This is utter gibberish. There never was [4:16] nor will be any science that would [4:18] support those ideas. [4:20] ADHD is not a qualitative different [4:23] state of humanity [4:25] from other people. It is much more like [4:27] being better or worse at writing, taller [4:31] or shorter in your height, better or [4:33] worse at language. Those are [4:35] quantitative differences. [4:37] That's important because otherwise we [4:39] stigmatize these people as coming from a [4:42] different planet. You know, one is from [4:43] Venus, another from Mars [4:45] to popularize or to take up a popular [4:49] view of gender differences between men [4:51] and women, but you get the point. [4:54] People with ADHD are not different from [4:56] normal other than in the degree of the [4:58] delay. Now, what is it that is delayed? [5:01] Two traits. [5:03] The first is not the one after which the [5:06] disorder is named. [5:07] In that sense, the disorder has been [5:09] misnamed. [5:10] The first deficit to appear is [5:12] inhibition. [5:14] A failure to develop at appropriate [5:16] inhibition of your behavior and this [5:19] will often emerge in the preschool [5:21] years. And its first sign is usually [5:23] hyperactivity, though it doesn't need to [5:25] be so. [5:27] But it typically is. You have an [5:28] individual who is behaving too much, who [5:32] is not suppressing irrelevant behavior [5:35] the way other children are able to do. [5:37] We will see this in their motor actions. [5:40] There's a lot of action coming out of [5:42] this child. We will see it in their [5:43] verbal behavior. There's a lot of words [5:45] coming out of this individual. [5:47] And we will see it in their intrusive [5:49] and disruptive motor and verbal behavior [5:52] as well. But along with that, there is a [5:55] cognitive impulsiveness. This snap [5:58] decision-making, this quickness to do [6:00] the first thing that pops into your head [6:03] without due delay and due diligence, [6:06] thinking about what the consequences [6:08] will be. [6:10] And then we will also see [6:13] the restlessness. [6:15] Not just the gross motor activity, but [6:17] the seat restlessness, which I think [6:19] affects their school performance more [6:21] than the gross motor activity does. But [6:24] this will decline with age. So, that is [6:26] why hyperactivity is no longer the name [6:28] of this disorder because it declines [6:30] steeply and by adolescence it's nearly [6:31] gone and by adulthood it's an internal [6:34] state. [6:35] It's a feeling inwardly of a need to be [6:38] busy in doing multiple things. And it's [6:41] a busyness of one's mind, one's ideas. [6:45] There was a restless quality to their [6:47] cognition. [6:49] But not to their outward behavior. In [6:51] fact, our research has shown that [6:53] hyperactivity is of no diagnostic value [6:56] in adulthood. In fact, being restless is [6:59] more associated with anxiety disorders [7:01] by the time you're 30 than it is being [7:03] associated with ADHD. We just don't pay [7:06] attention to it. It's of no relevance to [7:08] diagnosis. [7:10] So, let's understand that the real [7:11] problem here is not [7:13] restlessness. It is in fact inhibition. [7:17] There is a failure to develop [7:19] appropriate inhibition and it affects [7:21] your behavior, it affects your words, it [7:23] affects your mind and your thoughts. [7:26] And we need to return to the idea, which [7:29] we have gotten rid of, that it affects [7:31] your emotions. [7:33] For the first 170 years of the history [7:36] of ADHD in the medical literature, which [7:38] began in 1798, not 1902, [7:42] eight years ago, [7:44] the last remaining copy of a medical [7:45] textbook was discovered at Kent State [7:48] University. [7:49] This textbook was written by the [7:51] Scottish physician, then living in [7:53] colonial America, [7:54] Alexander Crichton. And Crichton had [7:57] written a medical textbook in which [7:59] there is a chapter entitled diseases of [8:02] attention. [8:03] And it is the first description of this [8:06] disorder, and it's very good, by the [8:07] way. [8:09] So, ADHD did not begin in 1902, it [8:12] started in 1798 as far as the first [8:15] initial medical reference. And from that [8:17] point on until 1976, [8:22] emotion was part of ADHD. [8:26] Every major theorist, every paper, every [8:29] science paper, including that of Mark [8:31] Stewart, one of the first major [8:33] scientific descriptions, the Canadian [8:35] papers by Weiss and Heckman and Werry [8:38] and Douglas and others back in the '60s [8:40] and '70s, [8:41] all included emotional impulsiveness as [8:45] part of this disorder. [8:47] But the DSM parsed it aside [8:50] and made it an associated problem in [8:53] some people. [8:54] It isn't. It is as much a core feature [8:57] of this disorder as is any other symptom [8:59] in the DSM. [9:01] And that was our mistake. [9:03] And it needs to be returned to our [9:05] understanding of ADHD. [9:08] By emotional impulsiveness, I mean this [9:10] quickness to anger, to be easily [9:12] excitable, to have low frustration [9:14] tolerance, to be easily angered by [9:17] things around you, [9:19] and to display your emotions much more [9:21] quickly than other people do. Now, this [9:24] is not a mood disorder, even though it [9:25] starts to look like one. Mood disorders [9:28] are where you are generating too much [9:30] emotion. What ADHD is is a failure to [9:33] regulate normal emotion. [9:36] It is a self-regulation disorder. [9:39] The feeling you're having is normal, [9:41] that you are not moderating it is not. [9:44] It is this inability to self-soothe, [9:48] to self-calm, [9:50] and to then moderate the emotion to be [9:52] more acceptable for the context and for [9:55] what you hope to accomplish here, the [9:57] goal that is at hand. Your long-term [10:00] welfare is at stake. Can you modify that [10:04] emotion [10:05] to be more socially acceptable, to be [10:08] less costly, less damaging? [10:11] That is as much a part of ADHD as [10:13] anything else, and we are pushing the [10:15] DSM-5 committees. There are several [10:18] to reincorporate emotional impulsiveness [10:22] and this emotional dysregulation [10:24] as being a part of this disorder, [10:26] because it loads on this dimension. You [10:29] cannot be impulsive in your behavior and [10:32] not be impulsive in your emotions. That [10:33] is impossible because they are a unity. [10:36] They go together. [10:38] Emotion is welded to everything you say [10:41] and do. [10:43] Sometimes it is benign and bland. Other [10:46] times it is powerful and intense. It is [10:49] the emotional coloring of the behavior [10:52] we display. If you are impulsive in one, [10:55] you must be in the other. [10:57] That needs to get reintroduced back into [11:00] ADHD for a number of compelling reasons, [11:03] not just because historically it was [11:05] always there, but because it explained [11:08] so much more [11:09] than the current view of ADHD explains. [11:12] As I will show you, ADHD children are 11 [11:15] times more likely to develop [11:16] oppositional defiant disorder within 2 [11:18] years of the onset of their ADHD. Why? [11:22] What do those disorders have to do with [11:24] each other? Now they're treated as [11:25] simply comorbidity. Oh, well, they go [11:28] together, but we're not sure. [11:30] But if you put emotion back into ADHD, [11:33] you see the connection right into ODD [11:35] because everybody with ADHD is [11:38] automatically subclinically ODD [11:40] at the get-go. It's only going to take [11:43] one more symptom to cross the diagnostic [11:45] threshold. [11:47] In other words, ADHD causes ODD. [11:52] That is an important thing to understand [11:54] because the ODD, while it does have some [11:56] social influences over it, [11:59] half of ODD is the inability to manage [12:02] frustration, impatience, and anger. And [12:06] that will set you up for the second [12:08] component of ODD, which is interaction [12:11] conflict, defiance, arguing. [12:15] But, the first four symptoms of the [12:17] eight in ODD are mood, [12:21] anger, temper, hostility, easily [12:24] annoyed, irritability. And that is part [12:27] of ADHD. [12:28] So, we need DSM-5, and we need families [12:32] to both understand that emotion goes [12:35] with this disorder. It is not a separate [12:38] comorbidity in some cases. [12:41] And now we know why when we treat ADHD, [12:44] particularly with the medications that [12:46] we use, we get nearly as much reduction [12:49] in ODD as we get in ADHD. And when we [12:51] don't, [12:53] it is because of the social conflict [12:55] component, which is learned. [12:58] And we will have to unlearn that little [13:00] piece, but the mood component is the [13:02] ADHD component. [13:04] Now, by returning emotion into ADHD, it [13:07] also helps families to understand some [13:09] of the other life course risks. [13:11] 50 to 70% of ADHD children are utterly [13:14] rejected by close friendships by second [13:17] grade. [13:18] It is, in fact, one of the more [13:20] devastating consequences of this [13:22] disorder is this inability to make and [13:25] keep close, sustained friendships with [13:28] other children. And it is heartbreaking [13:32] for parents to see this happening [13:34] that their child is not as liked as [13:36] other children, that the sleepovers, the [13:39] going to the movies, and the other [13:41] social events in which other children [13:43] celebrate their peer relationships are [13:46] shut off for this child. [13:48] Why is it there? The single best [13:51] predictor of peer rejection is that [13:54] symptom. [13:55] The emotional impulsiveness. Friends [13:58] forgive you your distractibility, your [14:00] forgetfulness, your working memory [14:03] problems, and even your restlessness. [14:05] They will not forgive your anger, your [14:08] hostility, the quickness with which you [14:10] emote to other people [14:12] because it is offensive. [14:15] It is socially costly. [14:17] So now we can begin to understand the [14:19] numerous social problems [14:22] that ADHD children are prone to because [14:24] it arises from this aspect of the [14:27] inhibitory deficit. [14:29] There are other things that it explains. [14:30] I could do a whole hour and a half as I [14:32] did a month ago in Toronto on the [14:34] importance of emotion in ADHD. I won't [14:36] go there. [14:37] But suffice to say that it explains the [14:39] road rage during driving, the job [14:42] dismissals, which are not the result of [14:44] inattentiveness, but of being too quick [14:47] to anger, [14:48] too quick to express raw emotion in the [14:51] workplace of which employers are not [14:54] tolerant, especially if it occurs with a [14:56] customer. [14:58] And it also explains to us the marital [15:01] difficulties and the parenting [15:03] difficulties these children may be prone [15:05] to [15:06] because the single best predictor of [15:08] marital problems in the adult with ADHD [15:10] is not distractibility. [15:12] It is emotion. [15:15] So we can begin to paint a better [15:17] picture of understanding ADHD in its [15:20] life course risks by understanding the [15:22] nature of the inhibitory problem and [15:25] that it includes emotion as part of it. [15:30] And that's just slide one. I've got 85 [15:32] slides. [15:35] Do you see why I'm concerned? [15:39] 15 minutes to do a slide. All right, so [15:42] we better get rolling here, but I [15:43] thought you ought to know where we're [15:44] going. And by the way, in case you [15:46] hadn't noticed, I will not talk down to [15:48] you today. [15:49] I will treat you as if you were my [15:50] colleagues, my students, my peers [15:53] because I think that parents attend [15:55] these things to learn and that's not [15:57] going to happen if I have to dumb this [16:00] material down and it is also insulting [16:03] and I won't insult your intelligence [16:04] either. You're knowledgeable people. [16:06] I'll speak to you frankly using the [16:09] scientific terminology. [16:19] The second dimension, failing to develop [16:21] on schedule, [16:22] will appear about two to three years [16:24] after the first. [16:25] And this is known as the attention [16:27] deficit, but it isn't. [16:29] Here again, we have a misnomer. [16:32] There are at least six or seven kinds of [16:35] attention and supporting networks in the [16:37] human brain. They are not all disrupted [16:39] by this disorder. [16:41] What we want to know is which one. [16:43] To help us with differential diagnosis, [16:45] to help us tell ADHD from an anxiety [16:47] disorder and from autism [16:49] and all the other psychiatric disorders, [16:51] which all interfere with attention at [16:53] some point in life, [16:55] ADHD is not the only attention deficit. [16:58] We need to be more precise. [17:01] If someone comes to us and says, "My [17:02] child or I am inattentive." That is [17:05] useless diagnostically. [17:08] What I need to know is the nature of the [17:10] inattentiveness. And we have now known [17:13] for a decade that the inattentiveness [17:15] that we see in ADHD is distinct from [17:18] that produced by all other disorders [17:20] because it is most I think accurately [17:23] described as a failure of persistence. [17:27] The first attention problem is [17:29] persistence toward a goal. Notice that [17:32] this implies behavior, motivation, and [17:35] the future. [17:36] That is very important. The other forms [17:38] of attention do not. [17:40] ADHD is not a problem of perception, of [17:43] filtering, of processing, of how the [17:45] posterior part of our brain functions. [17:47] It is a problem with the motor part of [17:51] the brain, this frontal lobe. Can you [17:54] sustain action toward a goal adequately [17:57] to attain it? [17:59] That implies a motivation deficit, and [18:01] that is true. [18:02] And it implies future-directed behavior, [18:04] and that is true. ADHD is a failure to [18:08] direct behavior forward in time. [18:11] We cannot persist toward these delayed [18:15] endpoints in life, the tasks, the goals, [18:18] the things that need to get done. [18:21] So, persistence is deficit one in the [18:24] area of attention. Now, to persist [18:26] toward a goal, you must be able to [18:28] resist distractions. [18:30] But that, too, is not a perceptual [18:32] issue. It is a motor issue. The person [18:35] with ADHD [18:36] does not have problems with perceiving [18:39] distractors better than others. [18:42] It is that they respond to distractors [18:44] more than others. [18:45] And that is an inhibitory failure, not a [18:48] perceptual difference. [18:50] You and I may all hear the noise in the [18:52] kitchen. The person with ADHD is [18:55] compelled to react to it. Oh, did you [18:57] hear that? I guess they're washing [18:58] dishes. Maybe I'll stop in and and take [19:00] a look. Did you know I was a dishwasher [19:02] when I was back in college? That's how I [19:04] earned my way. Do you see what's going [19:06] on here? You all heard the dish, but it [19:08] was irrelevant to what we're here to do [19:10] today. [19:11] But to the ADHD individual, the [19:13] distraction [19:15] is going to provoke a response, and the [19:17] response can't be inhibited. [19:19] And now they're off to the races, [19:21] skipping from one thing to another to [19:23] another. [19:24] Now, there is a third aspect here that [19:27] is impaired, but it is not one of [19:29] attention. [19:31] Most people, when they are distracted, [19:33] reengage the incompleted goal. [19:35] The person with ADHD is far less likely [19:37] to do so, and this has nothing to do [19:40] with attention. [19:41] This is working memory. [19:44] So, I would want a family to understand [19:46] that there's more here than [19:47] inattentiveness. [19:48] There was a working memory disorder, and [19:50] I would want them to know that working [19:52] memory is one of the five special [19:54] executive functions of the human brain, [19:58] suggesting that ADHD is EFD [20:02] executive function deficit disorder, [20:04] because working memory is where we [20:06] remember what we're doing. [20:08] It is remembering so as to do. It is [20:10] consciously, effortfully holding in mind [20:13] the what, the when [20:15] of what we are doing. [20:19] It's what you lose at my age and when [20:21] you hit menopause. [20:23] You do not lose memory. You lose working [20:28] memory. You forget what you were doing, [20:31] where you were going, what the goal was, [20:34] the steps to the goal, how you were [20:36] getting there. It is that that allows [20:38] you to reengage the incompleted goal, [20:41] because you were holding in mind the [20:43] goal. It is that which ADHD children and [20:46] adults will lose. The goal is gone. It [20:49] is forgotten, and now anything else [20:51] compelling around them will capture [20:53] their behavior. [20:54] Hence the symptom, skips from one [20:57] incompleted activity to another. The [21:00] ability to reengage a goal is a working [21:02] memory disorder. [21:04] And that's what they cannot do. And this [21:06] begins to open the door on the [21:08] possibility that the other four [21:10] executive functions are impaired as [21:12] well. More on that later. [21:14] So, let's understand that there are [21:15] three interacting attentional problems, [21:18] but that they are best thought of as [21:20] executive deficits, not attention [21:23] deficits. [21:24] And they are the problem with [21:25] persistence toward the future, [21:27] resistance of distractions along the [21:29] way, [21:30] and working memory. [21:33] And now you understand the nature of [21:35] this attention problem from the one [21:37] that's produced by anxiety, and [21:39] depression, and autism, and all the [21:41] other disorders including the learning [21:42] disabilities, which have nothing to do [21:44] with these. [21:47] I would want families to understand that [21:49] there is more to ADHD [21:52] than just the inhibition and these [21:54] attention and working memory problems. [21:56] That at its heart, [21:58] in its soul, it is a disorder of [22:01] self-regulation, [22:03] not one of attention. I think the [22:05] biggest problem we have had as a group [22:07] in convincing the general public about [22:09] the seriousness of our children's [22:11] disorder versus autism or schizophrenia [22:14] or the other disorders is the very name [22:16] itself is trivial. [22:18] ADHD, [22:20] go to Starbucks. Good God. Have some [22:23] caffeine. We got more serious fish to [22:25] fry here in psychiatry than the fact [22:27] that you just can't pay attention, [22:28] right? [22:30] Part of the reason that our disorder, [22:32] that the name of this disorder is so [22:34] often pilloried in the media, [22:36] is because I think we misnamed it, [22:38] right? [22:39] This is a developmental disorder of [22:40] self-regulation, [22:42] not of attention. And that is a serious [22:46] disorder, [22:47] as serious as manic depression, [22:49] and in its own way, as autism. [22:52] But it doesn't convey that to people if [22:54] they understand it only as ADHD [23:00] as opposed SRDD, [23:03] a self-regulatory [23:05] developmental disorder. [23:07] So, I would want families to understand [23:09] the seriousness of this. [23:12] That this isn't simply inattention. [23:14] There are some profoundly unique human [23:17] traits that are not emerging as they [23:19] should in this individual. [23:22] And if you'll understand that, you'll [23:23] understand the bigger picture, the why [23:26] of everything. If it's just an attention [23:28] problem, why am I seeing impairments in [23:30] virtually every domain in which this [23:32] child is asked to function? [23:34] That would not come from just [23:35] inattentiveness, but it would come from [23:38] an executive function disorder, a [23:40] self-regulatory disorder. [23:42] So, I would want parents to understand [23:44] that this is the essence of this [23:46] disorder, [23:48] self-regulation. What is that? It is, [23:50] first of all, the ability to [23:52] consciously, willfully, [23:55] choose to inhibit your behavior, [23:59] and then to engage in a series of [24:01] self-directed actions. That is, after [24:04] all, what self-control is. You start to [24:06] do things to yourself. [24:10] These are responses that are not [24:11] directed at the world around you. [24:13] They're directed at you, right? [24:15] You're trying to change your behavior in [24:17] some fundamental way. [24:20] The second part of self-control that [24:22] your child struggles is not just the [24:24] stopping, [24:26] but the thinking. [24:27] The thinking is the self-directed [24:29] activity, the stuff I am doing to [24:31] myself. [24:33] Why would I do these things to myself? [24:35] To change my behavior from what it would [24:38] otherwise be, and why would I do that? [24:41] To change my future. Self-regulation [24:44] is not just for short-term [24:47] self-improvement. [24:49] It's for long-term self-improvement. [24:51] It's to see to your own welfare over the [24:53] long term. [24:55] Should you act this way given the [24:59] sustained or delayed consequences that [25:01] lie ahead for you? That is what you must [25:03] stop and think about [25:05] and that is what they don't stop and [25:07] think about. [25:08] The delayed consequences. [25:12] So, your child is not just inattentive. [25:15] They cannot stop and engage in a series [25:19] of self-directed actions that they will [25:22] now use to modify and moderate their [25:25] behavior [25:26] so as to bring it in line with their [25:29] long-term welfare. [25:31] The future. [25:33] And that's what your your child is [25:34] struggling so mightily with [25:37] in their development. It's what the [25:39] other kids are acquiring and your child [25:41] is so far behind in. [25:52] I would want parents to understand [25:54] something that the vast majority of the [25:56] lay population does not understand. [25:58] Self-control is not learned. [26:03] It is not the result of your upbringing [26:06] and how good your parents were. This is [26:08] one of the most profound insights from [26:10] our research on ADHD. [26:13] ADHD, as we will see, is largely a [26:15] neurogenetic disorder. But then let's [26:17] pursue the implication. If that is true [26:19] and ADHD is a self-regulation disorder, [26:22] then self-control is largely [26:23] neurogenetic in origin. [26:25] That has a philosophically profound [26:28] conclusion. The vast majority of [26:30] variation in the people sitting in this [26:32] room and their ability to manage their [26:34] behavior [26:35] is not from how they were raised. [26:38] It is a part of who they are. It is a [26:40] part of their neurogenetic gifts. [26:44] And that is very stunning indeed. [26:49] That our capacity for regulating [26:51] ourselves [26:52] is a neurobiological trait, [26:55] not some socially learned phenomena that [26:58] you just happen to pick up from your [27:00] parents. [27:02] So, I would want them to know that ADHD [27:05] being a self-regulation disorder [27:08] is arising out of neurogenetic causes, [27:11] and that this inability to direct [27:13] behavior toward yourself [27:16] comes from impairments in the following [27:18] five executive abilities. [27:20] And these have to do with brain [27:21] development, not with training. [27:24] It does not mean that training cannot [27:26] enhance them. It means that they don't [27:29] originate [27:30] at the beginning [27:32] in training, in the social environment. [27:36] The social environment requires that [27:38] they be there already, [27:40] and then it will help to shape them to [27:42] become more proficient. Think of your [27:44] language ability. You didn't learn [27:46] language, but it doesn't mean that you [27:49] can't become more proficient in how you [27:51] speak and how you write. [27:55] But speaking and writing are not [27:56] accounted for on the basis merely of [27:58] training by your parents. You're going [28:01] to develop a language no matter where [28:02] you grow up. That is a neurobiological [28:05] trait, and it unfolds as the brain [28:07] unfolds. It is an instinct, and so is [28:11] self-control. [28:12] But self-control can be reduced to these [28:14] five things. What are the five things [28:17] you do to yourself? These are the things [28:19] your child struggles to do. Number one, [28:22] can you stop? [28:23] Can you wait? [28:25] Because as Rabelais said in the novel [28:28] Gargantua, which most of you have never [28:30] read, I'm sure, but it is where this [28:32] phrase comes from. [28:34] Everything comes to those who can wait. [28:38] The waiting is the tough part. [28:41] You must build in a pause [28:43] between the event and what you plan to [28:47] do about it. [28:49] And in ADHD, there is no pause. [28:51] The event happens, and your response is [28:53] up, out, done. [28:55] It is as if there was no front part to [28:57] the brain. [28:58] It is as if you were like any other [29:00] species with a spinal cord. Event, [29:02] response, event, response. [29:05] Or as in a Gary Larson cartoon, remember [29:07] The Far Side? [29:08] Two amoebas, a husband and wife talking [29:10] to each other. One amoeba, the wife of [29:12] course, says to her husband, "Stimulus, [29:14] response, stimulus, response. Don't you [29:16] ever think?" [29:19] Characterizes ADHD right there, right? [29:23] Don't you ever think? [29:25] Once you stop, you will engage in four [29:28] subsequent actions. The first is mental [29:31] imagery. [29:32] You will recall the past, and you will [29:34] play a DVD of it in your head. You have [29:36] a theater in your mind. [29:38] It is your visual imagery system. [29:41] The mind's eye. [29:43] So, your child not only cannot stop, [29:45] they cannot visualize as well as other [29:47] children. And what they do not visualize [29:49] before they act is the past. [29:52] The relevant past. [29:56] Do you have experiences in this [29:57] situation previously? If so, what would [29:59] they have told you to do? [30:02] Lay people call this hindsight, and the [30:04] word sight is no coincidence. [30:07] You are visually imagining your history. [30:10] What does it have to say? And you lack [30:13] hindsight. [30:15] Now, this will lead to foresight. [30:17] You look back to anticipate. [30:20] What does ADHD lead to? No foresight. [30:24] You are not thinking ahead because you [30:26] weren't looking back, either. [30:28] Hindsight and foresight are the opposite [30:30] sides of the same coin. [30:33] Visual imagery. [30:35] So, you will not use your images of your [30:37] past [30:38] to tell you what to do. You will just [30:40] do. [30:42] And then by 5 years of age, you will get [30:44] the third executive deficit. You can't [30:46] talk to yourself. [30:49] Young children by 5 years of age are [30:51] beginning to internalize their speech [30:53] and use it on themselves. Just watch any [30:56] first and second grade classroom and you [30:58] will see this. [31:02] If you have a 3 to 5-year-old, you'll [31:03] hear it. They're talking to themselves [31:05] out loud most of the day whether anyone [31:07] is in the room or not. Listen to bedtime [31:10] and you will hear what I mean. [31:12] But over the next 10 years, this [31:14] external voice gets directed to [31:16] themselves and slowly made private and [31:19] mental in its form. [31:21] And so originates the voice in your [31:23] head. [31:24] And that voice in your head is there for [31:26] one very important reason. [31:28] It's to help control yourself. [31:30] You start telling yourself what to do [31:32] and it starts to work. [31:34] And now any family I would explain this [31:36] to would understand that not only can [31:37] your child not stop, not only do they [31:39] not have the mind's eye, they don't have [31:41] the mind's voice. [31:43] And what is there is very weak. It's not [31:46] controlling them. So now you know why [31:48] they can't do what you tell them to do. [31:50] They can't follow instructions, they [31:51] can't follow rules, they can't [31:53] internalize the rules of the situation [31:54] cuz everything I have just said [31:56] requires a voice in your head and they [31:59] don't have that. [32:03] The next comes from the first three and [32:05] that is the mind's heart. The ability to [32:08] manage your emotions so that they are [32:11] more socially acceptable. [32:13] So that they are consistent with your [32:15] goals. Not conflicting with your [32:19] welfare. [32:21] And so we will see the ADHD child as [32:23] we've already described them. Easily [32:25] frustrated, quick to anger, impatient, [32:28] and just overall more excitable and more [32:30] emotional than others. But what gets [32:33] lost in this explanation is is more [32:35] fundamental. [32:36] Our emotions [32:38] are our motivations. [32:41] If you cannot manage your emotions, [32:44] you cannot manage your motivation, [32:46] either. [32:47] Because the fourth executive ability [32:50] is the source of self-motivation. [32:52] Self-motivation is the fuel tank [32:55] for all future-directed behavior. [32:59] There is no getting ready for tomorrow [33:01] if there is no self-motivation. [33:04] So, what has the ADHD child lost here? [33:06] They cannot motivate themselves. What [33:09] does that mean? It means that you will [33:11] always be dependent on the environment [33:13] around you and its immediate [33:15] consequences [33:17] for how hard and how long you can work. [33:20] And if there are no consequences in that [33:23] context, [33:25] you cannot work. [33:27] You cannot persist. [33:28] You will not get it done. [33:31] The fourth executive ability now [33:32] explains to these parents why this child [33:35] can play video games for hours [33:37] and cannot do homework for more than a [33:39] few minutes. [33:41] Because the video game provides [33:43] external, continuous, 100% consequences [33:47] for interacting with it, [33:49] and the homework does nothing. [33:52] When a problem is solved on a sheet of [33:54] paper, nothing happens. [33:59] The consequences are delayed, [34:02] and therein lies the trouble. [34:05] So, the corollary of this is if you want [34:07] to see an ADHD person fail, you put him [34:10] in any environment where there are no [34:11] consequences, and I guarantee you [34:13] failure. [34:15] The work will not get done [34:16] because the person cannot self-motivate. [34:18] And this is not a choice, and this is [34:20] not willful, and this is not [34:22] a child who just [34:24] could, if they wished, wake up tomorrow [34:26] and smell the coffee and get busy and do [34:28] the work. [34:29] They cannot. This is an internal [34:31] neurogenetic executive failure. [34:35] You can't self-motivate like other [34:37] people. So, it doesn't matter what your [34:38] goals are, you won't get there. [34:41] Because self-motivation is required for [34:43] all goal-directed action. [34:46] The final executive ability, which will [34:48] not emerge until late childhood in the [34:50] person with ADHD, is the mind's [34:52] playground. [34:54] This is the ability to plan and [34:55] problem-solve. [34:57] How many different possible options can [34:58] you generate right now [35:01] to get around this problem? [35:03] This ability to simulate multiple [35:06] possible future options [35:09] is the highest executive function in [35:11] humans. [35:12] It is the source of all cultural [35:14] innovation, [35:16] but it originates in problem-solving. [35:19] How quickly in your mind can you think [35:22] of multiple ways to overcome the problem [35:25] you just encountered? [35:27] And people with ADHD will struggle with [35:29] this one as much as with the others. [35:32] So, if you want to understand ADHD as a [35:34] parent, you have got to understand these [35:36] are the five things that are delayed in [35:38] this child. [35:40] The ability to stop, to use visual [35:42] imagery, to use your mind's voice, to [35:45] use your mind's heart and emotion and [35:47] motivation, [35:48] and when called upon to do so, to [35:51] simulate multiple possibilities when [35:54] faced with a problem or when planning [35:56] out what you hope to do. [35:59] Planning and problem-solving. [36:01] Those are the five executive abilities. [36:03] We know where they are in the frontal [36:04] lobe. We know that ADHD children have [36:06] lost all five of them. [36:08] Actually, that's a bit of an [36:09] overstatement. It's not that they don't [36:11] have them, it's that they are quite [36:14] delayed, and we will discuss the delay [36:16] in a moment. [36:17] So, ADHD leads you to act on impulse, [36:21] not resist distraction. You are less [36:23] able to think back about what you are [36:25] doing, about the action that lies ahead. [36:27] You cannot use your hindsight, and [36:28] therefore your foresight is gone. You do [36:31] not plan ahead. [36:33] You live in the moment. [36:35] This is going to rob you of your sense [36:37] of time because the sense of time comes [36:39] from looking back to look ahead. Looking [36:41] across time and knowing where I'm going. [36:45] You will not have a subjective sense of [36:46] time, and that alone is going to be a [36:48] devastating adult disability. You have [36:51] the consummate disorder of time [36:53] management. [36:54] It's no wonder they're always late. [36:57] You will not be able to talk to [36:58] yourself, to reason with yourself, to [37:00] ask yourself questions, and to remind [37:02] yourself of the rules that are governing [37:03] the immediate situation. [37:05] And therefore it doesn't matter what [37:07] people say to you over and over and over [37:08] again, you won't do it. [37:11] No amount of nattering by your teacher [37:14] or your mother [37:15] will overcome the internal mind's voice [37:18] deficit. [37:20] You will not be able to use language as [37:22] well as other people to regulate [37:23] yourself. [37:25] And that is going to also lead you to [37:27] have a self-motivation problem and a [37:29] problem with regulating your emotions [37:31] and with self-soothing when you do [37:33] become emotional. [37:35] And then as we've said, you will have [37:36] trouble with planning and [37:37] problem-solving. So, if you want to know [37:39] the symptom list of ADHD, this is it. [37:42] The DSM is but a mere superficial [37:44] reflection [37:46] of the most obvious symptoms of these [37:48] five executive deficits. But to truly [37:51] understand ADHD, you need to know that [37:53] these five are all there [37:56] underneath. [37:58] To refer to ADHD as inattention is to [38:00] refer to autism as hand flapping and [38:02] speaking funny. [38:04] They are the most obvious symptoms of a [38:06] failure to develop the ability to relate [38:08] to others as special objects, as humans, [38:12] and that is what autism really is [38:14] underneath. [38:15] The rest of it is just the most [38:17] superficial set of symptoms. [38:20] So, I would want my family to understand [38:23] the profundity [38:25] of these deficits because inattention [38:28] hardly captures what is going wrong in [38:31] development. [38:33] Now, the DSM says there are three kinds [38:35] of ADHD. Let's shift gears here and get [38:37] honest. There is not a combined [38:39] inattentive or hyperactive type. [38:42] And DSM-5 will abandon them. They are [38:45] contaminated with each other because [38:48] there really is only a single ADHD in [38:50] the human population. And it varies in [38:52] its severity, and all these types have [38:54] done is to capture the degree of [38:56] severity of a single disorder. So, we [38:59] are now grappling for ways of [39:02] subgrouping people with ADHD that is [39:04] more clinically useful than the DSM view [39:08] is cuz the DSM view is useless. [39:11] And one of those ways that is very [39:13] compelling [39:14] is ADHD with and without conduct [39:17] disorder. The Europeans have done this [39:19] for decades. [39:20] In the North American continent, we [39:23] viewed conduct disorder as a [39:24] comorbidity. We are now looking at it as [39:27] a subgrouping [39:29] criteria. [39:31] Because you see ADHD children who have [39:33] conduct disorder [39:35] differ from ADHD children without it in [39:37] many, many respects. So many, in fact, [39:40] that we are now coming to think of this [39:41] subset of children who have both [39:43] disorders as a unique form of ADHD. [39:47] Because both disorders are more severe. [39:48] Both disorders start earlier. Both [39:51] disorders are far more persistent. And [39:53] the combination of these disorders will [39:55] predict ongoing difficulties with [39:57] antisocial behavior into adulthood. And [40:00] just as important, [40:02] these individuals carry a high risk for [40:04] psychopathy. [40:06] One in five of these children is a [40:08] budding psychopath. A child who lacks [40:11] guilt, conscience, empathy, and remorse. [40:16] A child who is a predator. [40:19] ADHD does not contribute to psychopathy. [40:23] But ADHD with conduct disorder is the [40:25] single best predictor of the psychopath [40:27] that we know of. [40:30] So, in the future we may be making the [40:32] same distinction the Europeans have. [40:35] That when conduct disorder and ADHD go [40:37] together, we have an extraordinarily [40:38] virulent disorder. [40:41] In case you're not familiar with conduct [40:42] disorder, it is the early appearance of [40:44] lying, stealing, fighting, and preying [40:46] on other children in an instrumental [40:47] way. [40:48] It is violating the rights of other [40:50] people for your own gain. [40:53] And it manifests early as the lying, the [40:55] stealing, and the fighting, but other [40:57] symptoms will develop thereafter. [40:59] The hyperactive type of ADHD never [41:01] existed because 90% of all cases go on [41:04] to get the combined type within 3 years. [41:08] And even if they don't get the combined [41:10] type, they're just one symptom short. [41:13] And so we call them subthreshold [41:14] combined types, but they're not a [41:15] different type. So, if we take these two [41:17] groups of children who really are just [41:19] variations on the good old combined type [41:21] of ADHD, that's 95% of all the kids put [41:24] into this group. [41:25] There is a small group left over who are [41:27] purely oppositional. [41:29] But because they have pure oppositional [41:30] disorder and they never had ADHD, they [41:32] will outgrow their ODD usually within 2 [41:35] to 4 years. [41:37] And their ADHD will go away. [41:39] Why are they there? Because parents [41:41] confuse ODD with ADHD. And if their [41:44] child is only oppositional, they often [41:45] report that they have symptoms of ADHD [41:47] when they don't. [41:49] But ODD alone is a relatively benign [41:51] disorder. [41:53] Unless it goes with ADHD, and then it is [41:55] a highly persistent disorder. [41:57] Now, the real action during the past [41:59] decade has been with this inattentive [42:00] group of children, most of whom are [42:02] combined type children. [42:04] And they grew up, and they lost some [42:06] hyperactivity along the way as we said. [42:08] And as a result, there's going to come a [42:09] time in adolescence, and especially by [42:11] adulthood, where they're just not [42:12] hyperactive enough to stay in the [42:14] combined type anymore. And so, [42:15] clinicians relabel them as inattentive [42:17] type, but they shouldn't. Once combined [42:19] type, always combined type. [42:22] But, you can see how at least half of [42:24] the individuals get put into the [42:25] inattentive group. They're just [42:27] outgrowing their hyperactivity. [42:29] And then, there's that group of children [42:30] who just are one or two symptoms short [42:33] of being in the combined type, but they [42:34] have the combined type anyway. They're [42:36] just a milder version of it. But, [42:38] interestingly, [42:40] 30 to 50% of the children who are now [42:42] called inattentive type [42:45] probably have a different disorder. [42:47] And researchers have called them SCT. [42:50] It's about 30 to 50% of all inattentive [42:53] type children. [42:54] And we now believe this is a [42:55] qualitatively unique disorder. [42:59] The debate now is whether this is a [43:00] separate type of ADHD, [43:03] a point with which I disagree, [43:06] or is it a qualitatively separate [43:08] disorder, a point with which I agree. [43:12] Why would I view this as a different [43:14] disorder? [43:16] First of all, the symptoms are the [43:17] opposite of ADHD, but you won't see them [43:19] anywhere in the DSM. But, these are the [43:21] most compelling symptoms that go with [43:23] SCT. [43:24] But, because these children also have an [43:26] attention problem, there was no place [43:28] else to put them because ADHD is the [43:30] only attention disorder in the DSM. So, [43:33] they get dropped into ADHD, even though [43:36] they have no symptoms in common with it. [43:39] These individuals have a problem with [43:42] processing information, which ADHD [43:44] children do not have. [43:45] These children have trouble with focused [43:47] attention, choosing what's important [43:49] from what's not. ADHD children do not. [43:51] Their problem is in persistence. [43:54] These people may have a long-term memory [43:56] storage problem, or it could just be the [43:58] same attention problem that appears when [44:00] they search their memory. [44:02] What is quite distinct about them is [44:03] that they are socially withdrawn, [44:06] reticent, shy, [44:08] apprehensive, and often prone to social [44:11] anxiety. But certainly, socially [44:13] reticent is a very good word for them. [44:16] This is not a word that would ever be [44:17] applied to an ADHD child. [44:22] Most importantly, and tellingly, they do [44:23] not have an inhibition disorder. An [44:25] inhibition is the heart of ADHD. [44:29] And therefore, they do not have a [44:29] self-regulation disorder. And ADHD is a [44:32] self-regulation disorder. [44:34] And these individuals do not have the [44:35] executive deficits that I just listed [44:38] for you that go with ADHD. [44:40] For those reasons alone, [44:42] you could argue that this is a distinct [44:44] disorder. But there are others. [44:46] There was a very low rate of [44:47] oppositional conduct disorder associated [44:49] with this type of child. [44:51] ODD and CD are much more common in ADHD [44:53] children. [44:54] These children have more anxiety [44:56] problems. [44:57] ADHD children, while one in four may [44:59] have anxiety, it's far higher in this [45:01] group. [45:02] We're not sure if depression goes with [45:04] this group. Both groups have about a 20 [45:06] to 25% risk of depression, but it [45:08] doesn't distinguish the two disorders. [45:11] When we interview families of these [45:13] children, their parents are concerned [45:14] only about school. [45:16] Nothing else. These are good kids. [45:19] Not disruptive outside of school. They [45:21] even have a few friends. Not as many as [45:23] other children, [45:25] but more than ADHD children will ever [45:27] have. [45:28] So, the big concern is, let's get that [45:30] school work done. And the mistakes [45:32] they're making in school. You interview [45:34] the parent of an ADHD child, they're [45:36] worried about everything. [45:39] Peer relationships, family functioning, [45:40] community behavior. [45:42] Not to mention what happens as the teen [45:44] gets older and starts driving and having [45:47] a job and managing money and becoming [45:49] sexually active. [45:52] SCT families don't worry about any of [45:53] that stuff. ADHD families worry, and [45:55] well they should. [46:01] These children mainly have trouble with [46:04] accuracy of school work. They get all [46:05] their work done and [46:07] half of it's wrong. [46:08] ADHD children don't do any work. [46:13] So, the difference [46:15] SCT is an accuracy disorder, ADHD is a [46:18] productivity disorder. That's a [46:20] qualitative difference. Another one is [46:22] that these children may be more prone to [46:24] math disorders, but we're not sure about [46:25] that. [46:27] These children come from quite different [46:28] families, families with the same kinds [46:30] of problems. [46:32] Higher rates of anxiety, [46:34] higher rates of learning problems in [46:35] school. [46:36] That's about it. [46:38] Children with ADHD come from families [46:39] with a lot more ADHD, a lot more school [46:42] failure, a lot more antisocial behavior, [46:45] alcoholism, depression, and drug abuse. [46:49] These children do not. [46:51] When we look at the treatments that work [46:52] for these children, and this has not [46:54] been very well studied, by the way, [46:56] but even here differences appear. [46:58] The medications for ADHD don't work very [47:00] well for these children. They don't hurt [47:02] them. You can try them. The lowest doses [47:04] are the best. They just don't help them. [47:06] In fact, in our study, only one in five [47:08] children was kept on their medication [47:10] after the trial. In ADHD, it's 92%. [47:15] These children are the best responders [47:16] to social skills training, but no [47:18] surprise, social skills training was [47:19] invented 40 years ago for shy people. [47:22] And we know it works best for shy [47:24] people, not for aggressive people. [47:27] And so, these children actually do very [47:29] well in social skills training. ADHD [47:31] children do not do well at all in social [47:33] skills training. [47:35] If they do, it needs to be done in the [47:36] school environment with the children [47:37] they go to school with, not in a summer [47:39] camp, and certainly not in some Saturday [47:41] morning clinic with other children [47:43] they'll never see again the rest of [47:45] their life. If you're doing that, you're [47:46] probably wasting your money. [47:49] So, if they benefit, it's because they [47:51] benefit by the teachers and others doing [47:53] the training outside of the clinic [47:56] environment, in the natural setting [47:57] where the social problems arise. And [47:59] even then, it's not so much the skill [48:01] training as prompting and queuing and [48:04] rewarding the occurrence of the skill. [48:06] Now, do be aware that research now shows [48:08] that one in four children put in a [48:09] social skills group will be made worse [48:11] by the group. This is known as deviancy [48:13] training and it happens to occur because [48:16] the more aggressive children in any peer [48:17] group will train up the less aggressive [48:19] children [48:21] to become more aggressive if only in [48:22] self-defense. It happens every [48:24] kindergarten year to normal children as [48:26] well. [48:28] So, clinicians need to be careful [48:29] because there are side effects to social [48:31] interventions. [48:33] 25% of ADHD children get worse by being [48:36] in a social skills group and we wish to [48:37] avoid that. Now, the MTA study has found [48:40] that anxiety is the best predictor of [48:42] response to the behavioral [48:43] interventions. [48:45] We could argue therefore that SCT [48:47] children are probably the best [48:48] responders to behavior modification even [48:50] better than ADHD children are. [48:52] We know that cognitive therapy, which is [48:54] teaching children to talk to themselves, [48:57] fails for ADHD. We know why now because [49:00] the mind's voice is not developing on [49:02] time. And in order for talking to [49:04] yourself to have any success, [49:06] you must have a normally developing [49:08] internal speech. And they don't. [49:11] At least not until adulthood and then [49:13] some cognitive training does help as a [49:15] supplement to medication. But in [49:17] childhood, cognitive training doesn't [49:19] help ADHD. But this isn't ADHD, so [49:22] shouldn't we revisit this? [49:25] And do cognitive training for SCT? [49:28] No one has done it. There's a [49:29] dissertation. You know somebody who [49:31] wants a dissertation? I just gave you [49:33] one. [49:35] What about medication? [49:37] Well, we don't know. We know the [49:39] stimulants aren't particularly wonderful [49:40] for them. They don't hurt them, but they [49:41] don't help them all that much. What else [49:43] might work? Well, I don't know honestly, [49:45] but let me conjecture. If I were writing [49:46] a grant tomorrow, [49:48] I might speculate that Strattera might [49:49] work for these children. [49:51] Only because these are more anxious [49:53] children and Strattera treats anxiety [49:55] when it coexists with ADHD. [49:57] So, maybe atomoxetine might have a shot [50:00] at this disorder. We don't know. [50:02] Nobody's done it. [50:04] Another drug that might be interesting [50:05] is Provigil, [50:07] modafinil. [50:08] Modafinil is an anti-narcoleptic [50:10] and it does seem to help people with [50:12] ADHD. It might help this group even more [50:14] because you remember those symptoms I [50:16] showed you two slides ago? [50:18] Does that sound a little narcoleptic to [50:20] you? [50:21] Lethargic, slow-moving, drowsy, staring, [50:26] inattentive. Hmm, maybe a brainstem drug [50:28] might help you. Again, all speculative. [50:31] We don't know. [50:34] By the way, that is all we do know on [50:35] SCT, so please don't ask me any more [50:36] questions about it cuz [50:39] you now know everything I know. [50:42] What I do want you to know as a family [50:44] is to understand that that's not ADHD. [50:47] ADHD is quite different from that. And [50:49] so, if you happen to have an SCT child [50:51] or you know someone who does, please [50:53] don't tell them to read the books on [50:54] ADHD. They will be sadly misinformed. [50:57] They will be told of all kinds of risks [50:59] and all kinds of treatments which, as [51:00] far as we know, have little if any [51:02] application to these children. [51:04] There is no book for parents on SCT, not [51:06] yet, nor should there be. We don't know [51:08] enough. [51:09] But researchers are now studying these [51:11] children. The very first [51:13] psychological treatments for SCT were [51:15] published about a year ago [51:17] at the University of California, San [51:19] Francisco. [51:20] And so, we're now beginning to see more [51:22] and more research on SCT children as [51:24] distinct from ADHD children. But what I [51:26] would want a family of an SCT child to [51:28] understand is that this isn't ADHD. [51:32] So, what you should be worried about are [51:34] not the things families of ADHD children [51:36] should be worried about. It's pretty [51:37] much going to be a school-based issue. [51:40] And the treatments that don't work for [51:42] those kids might well work for your [51:43] child. [51:44] And And treatments that do work for [51:46] those kids, such as medication, might [51:48] not be so great for your child. No harm, [51:51] but not necessarily so great. [51:58] Now, the next point I'd like a family to [52:00] understand and we're only on number six. [52:03] Whoa. [52:05] 25 to go. [52:09] That the deficits in these executive [52:10] abilities chiefly arise from problems [52:13] with brain development. So, we're going [52:14] to do a very quick 3-minute crash course [52:17] on causation. [52:20] What causes ADHD? [52:22] Multiple things. [52:24] But all of them [52:26] fall into the realm of biology. We now [52:28] know that you cannot turn a normal child [52:30] into an ADHD child by exposing them to [52:32] any social influence. It's not possible. [52:35] Not going to happen. [52:36] We also know that these causes can [52:37] interact with each other. I'll show you [52:39] a slide on that. Very interesting. [52:41] Multiple biological hazards may be [52:43] interacting to produce the disorder. [52:45] We now know where in the head this is [52:46] coming from. [52:48] So, if someone tells you we don't know [52:49] where in the brain it is, they're wrong. [52:51] Go to the library. Please read a [52:52] journal. [52:55] We know that social factors alone do not [52:57] cause this disorder. But social factors [52:59] are very important. Kindly do not leave [53:01] this room and say that Russ said that [53:03] social factors don't matter. I didn't [53:04] say that. I said they don't cause it. [53:07] But they do matter in three important [53:08] ways. [53:09] First, the resources you will have [53:10] available to treat this child are very [53:12] much a function of the social [53:13] environment around you. [53:15] Second, impairments your child will [53:17] experience are very much a part of the [53:19] situation. [53:21] You can rearrange environments so [53:22] they're less impairing. [53:24] Third, comorbidity. We know that other [53:27] disorders that link up with ADHD have [53:28] some social contributors to them. [53:31] Oppositional disorder, conduct disorder, [53:34] anxiety disorder, and depression all [53:36] have social contributions. Indeed, 40 to [53:39] 50% of the variation in those disorders [53:42] is the social environment. [53:44] So, while the social environment doesn't [53:47] cause this disorder, [53:48] I would want families to understand that [53:50] doesn't mean it's not important or [53:51] irrelevant. It's important for several [53:53] other very important reasons. [53:56] Now, we know that a third of all ADHD is [53:59] acquired, [54:00] not genetic, and that most of those [54:02] acquired cases occur during pregnancy. [54:05] And these are the things that we have [54:06] found that are likely to cause ADHD in [54:09] the unborn child. Because all of these [54:11] disrupt the formation of the frontal [54:14] lobe of the brain. But we also know that [54:16] about 5% of ADHD can occur after birth [54:19] as a result of various traumas and [54:21] infections and other things that can [54:23] affect ongoing brain development in [54:25] these five crucial areas. [54:28] And it is the acquired cases that are [54:29] most likely to have seizures. We know [54:31] that lead poisoning, [54:34] treating leukemia, that's right, the [54:35] treatments for leukemia can cause ADHD. [54:38] We know that strep bacteria contributes [54:40] a small amount of ADHD. Why would the [54:43] strep bacteria do that? Because the [54:46] strep bacteria has a protein on the [54:48] outside of it, [54:50] and that protein is identical to [54:52] proteins that occur in the brain. [54:54] And therefore your immune system attacks [54:56] your brain. [54:58] So, it's not the bacteria. It's the fact [55:00] that the immune system can't distinguish [55:02] the bacteria from nerve cells. And this [55:05] damages certain parts of the brain, and [55:07] one of those parts causes ADHD. It's not [55:09] a very common problem, but it can [55:10] happen. [55:13] We know the brain regions that are [55:15] giving rise to ADHD, and we know that in [55:17] two-thirds of children the reasons for [55:19] these brain regions being smaller has to [55:21] do with genetics, about which I will say [55:22] more in a moment. But let's at least go [55:24] through these brain regions. [55:26] The five regions of the brain that are [55:27] interconnected to each other and give [55:28] rise to this disorder are the right [55:30] frontal lobe, right over here, [55:32] especially over the eyebrow, [55:34] and the connections from there deep into [55:36] the brain called the basal ganglia. I'll [55:37] show it to you in a moment. [55:39] And then there are connections from the [55:40] central part of the brain back to the [55:42] very primitive structure at the back of [55:44] the brain known as the cerebellum. That [55:46] is also smaller. [55:47] And then there's a very special part of [55:49] the brain that lies right between the [55:52] eyes in the midline going back on the [55:55] walls of the two hemispheres as they [55:57] come together. And deep inside on those [56:00] walls is the anterior cingulate. [56:02] And that is where the emotional [56:04] dysregulation originates. [56:06] Finally, there is the corpus callosum, [56:08] which allows the two hemispheres to talk [56:10] to each other, but it's no surprise. [56:12] The front part of the brain is smaller [56:13] than the corpus callosum has to be [56:15] smaller. [56:16] The size of this network is directly [56:18] related to severity of ADHD. [56:20] And in children who inherit the [56:22] disorder, this these parts of the brain [56:23] are about 3 to 10% smaller. That's it. [56:26] Just 3 to 10%. Doesn't sound like much [56:29] and it isn't. [56:30] But it's enough to cause this disorder. [56:32] More importantly, it's not enough to use [56:35] brain imaging for diagnosis. [56:37] These differences are so small and so [56:39] subtle that you could not use them to [56:41] classify people. Which is why no brain [56:44] imaging technique, including Dr. Amen's [56:47] SPECT scanning, [56:49] is of any value for diagnosis. [56:52] We know that there are very few gender [56:54] differences in these networks, though [56:55] there are some that are interesting. I [56:57] won't talk about them today. And we know [56:59] that these differences are relatively [57:01] persistent over time. [57:04] The structural differences will [57:05] normalize by about 16 to 18 years of [57:07] age. That is the size of the brain, but [57:10] the functioning of the brain will not. [57:12] And contrary to Tom Cruise and the [57:14] Scientologists, these brain differences [57:16] have nothing to do with giving [57:17] medication to these children. [57:19] So, let me show you the parts of the [57:20] brain we're talking about very quickly. [57:22] Let me get my cursor up here on the [57:23] screen. This is the right orbital [57:26] frontal area right here. [57:29] This part of the brain projects back in [57:31] between those two hemispheres. There's a [57:33] structure you can't see, it's right [57:34] about in here, and that's the anterior [57:36] cingulate. And then there are [57:38] projections back into the basal ganglia [57:40] right here. [57:42] And then back to the cerebellum right [57:44] there. And it's the right side of the [57:46] cerebellum in the central part that's [57:47] smaller. Indeed, [57:50] most interesting is that research has [57:52] found in the last 2 years that the [57:54] parents and the brothers and sisters of [57:56] ADHD children also have smaller neural [57:58] networks in exactly these areas, except [58:01] for one. [58:03] And that is the cerebellum. [58:05] Which tells us that of all of these [58:07] differences, most of them are part of [58:09] the family phenotype. Even if the family [58:12] member never shows the disorder, they [58:14] carry these patterns of [58:16] underdevelopment. [58:17] What may make the disorder break through [58:19] into full disorder is that something [58:22] happened to that cerebellum. [58:26] That's an interesting possibility. [58:28] Remains to be replicated, but that's a [58:30] finding from research at UCLA. [58:33] So, what's going on? The brain is not [58:34] developing on time. We know that from [58:36] the Montreal, New York, Washington [58:39] multisite study, in which 223 [58:43] ADHD normal children were scanned [58:45] serially over a period of about 10 [58:46] years. This is the first developmental [58:48] neuroimaging study. [58:50] And what did it find? [58:52] That the frontal lobe of the brain, [58:53] primarily, is about 2 to 3 years delayed [58:56] in its growth. This is a study of [58:58] growth, not function. [59:00] Just brain size. And what you're looking [59:03] at is a top-down view of the brain, and [59:05] these are the frontal lobes. [59:08] So, there's about a 2 to 3-year delay in [59:10] your brain development, and you can see [59:11] it in the right and in the left [59:13] hemisphere here as well. So, this was a [59:16] groundbreaking study demonstrating that [59:18] the brain is late in these crucial [59:21] executive areas to develop. Now, the [59:24] better parent is going to be asking me [59:26] about this. [59:27] This is not the frontal lobe. What the [59:29] heck is that? All right? [59:32] That's back where your visual cortex is. [59:34] Why would that be involved in ADHD? [59:37] The second executive function is visual [59:39] imagery. [59:41] And that's involved in visual imagery. [59:44] This part of the brain developed too [59:46] early. [59:47] This is the motor strip. And it [59:49] developed about two or to three years [59:51] earlier. And it's where the [59:52] hyperactivity is coming from. [59:54] So, you've got a motor strip that's [59:55] generating behavior and a frontal lobe [59:58] that's not regulating it. [60:00] So, I would want parents to understand [60:02] that this is a brain-based disorder. [60:05] And that it results in a maturational [60:07] lag in how rapidly these parts of the [60:09] brain are developing. [60:10] I would want the family coming to my [60:11] clinic to understand that most of these [60:13] differences originate in genetics. [60:15] But that about a third of the male [60:17] patients that we see may well have [60:18] acquired their ADHD. [60:20] In girls, it's far less than that. In [60:22] fact, it's fair to say that the vast [60:24] majority of girls have the genetic type [60:26] of the disorder. But about a third of [60:28] the boys may have acquired their [60:29] disorder. We know that ADHD runs in [60:32] families and have for 40 years. Here are [60:33] the risks if you have an ADHD child. [60:36] 25% of their brothers and sisters will [60:38] have the same disorder. If you're an [60:40] identical twin, that risk is 78% [60:43] Notice that the closer people are [60:45] genetically related, the higher the risk [60:47] if one has the disorder that the other's [60:48] going to have the disorder. Now, if we [60:50] bring in their mothers and evaluate [60:51] them, upwards of 1/5 of their mothers [60:53] are still adults with ADHD. [60:56] And nearly a third of their fathers are [60:58] currently ADHD. And if you add those two [61:01] together, it means that there's a 50% [61:02] chance that one of the parents sitting [61:04] across your desk [61:05] has the same disorder, probably never [61:07] diagnosed. [61:08] Which is why we now teach clinicians [61:10] that you should be screening every [61:11] parent that brings a child to your [61:12] clinic. Oh, and by the way, if you're an [61:14] adult with ADHD [61:16] 40% of your children will have the same [61:19] disorder. [61:20] That is a profoundly [61:22] genetic disorder. [61:24] Nearly half of the offspring of adults [61:26] with ADHD have ADHD as well. [61:30] We know from twin studies that the vast [61:32] majority of ADHD is due to genetic [61:35] differences. On average, 80% of the [61:37] differences in people in this room in [61:39] their ADHD symptoms are due to [61:40] differences in their genes. [61:42] And in the last few studies, it was as [61:44] high as human height, about 91%. [61:48] Twin studies allow us to calculate how [61:50] much of a trait is due to the rearing [61:51] environment, and it's zero. [61:54] All 40 twin studies published in the [61:57] last 20 years have shown that the [61:59] rearing environment has no influence on [62:03] this trait. [62:04] Yet, the public believes that ADHD [62:06] originates in bad parenting. [62:09] The twin studies also tell us that [62:11] there's a small percentage of ADHD [62:12] that's arising from non-genetic causes, [62:15] and those are those acquired injuries [62:17] that we talked about earlier. [62:21] And just in case you were wondering, [62:22] yes, we are discovering genes for ADHD. [62:25] We have had more success in this area of [62:27] psychiatry than with any other disorder [62:29] than I know of. [62:31] We now know from genome scans published [62:33] just last year, where we've scanned all [62:35] 35,000 active human genes for ADHD [62:38] genes, that it's going to be about 20 to [62:40] 25 sites. [62:42] And out of those 20 to 25 sites, we've [62:44] nailed down about five to seven of them. [62:47] And here's a few. [62:50] Want you to notice that there's a D in [62:51] front of the first four genes? It means [62:54] that those genes regulate dopamine in [62:56] the brain. [62:58] So, no surprise, the genes that regulate [63:00] dopamine are ADHD risk genes, and no [63:02] surprise that drugs that improve [63:04] dopamine in the brain work for ADHD. [63:08] Because those drugs are altering the [63:09] effects of these genes in the brain. [63:12] Which means that psychopharmacology is a [63:15] form of genetic treatment. Isn't that [63:17] fascinating? It's not a band-aid. It's [63:19] not a cover-up. [63:21] It's not missing the point. It's [63:23] actually helping to manage the [63:25] underlying genetic problems, if you [63:27] will, the genetic differences in the [63:29] brain. [63:31] Now, let me take one of these genes and [63:32] explain it to you cuz it's kind of cool. [63:34] I won't go through all the genes, but [63:35] bear with me. [63:37] This is a nerve cell that I pulled out [63:38] of your frontal lobe. Ouch, I'll bet [63:40] that hurt. [63:43] And if you look at this nerve cell, when [63:44] this little baby gets stimulated, an [63:46] electrical impulse is going to proceed [63:48] down this nerve cell, and as that [63:49] impulse reaches the end of the nerve [63:51] cell, these little packets of chemicals, [63:54] dopamine, [63:55] are going to move toward the outside [63:57] membrane and burst. [63:59] And as they burst, they're going to [64:01] spray dopamine out into that little gap [64:03] called a synapse. [64:05] And if there's enough dopamine out [64:06] there, it's going to cross over and bind [64:08] to this membrane, [64:10] and it's going to fire the next nerve [64:11] cell in line. And that's how your brain [64:13] works. [64:14] Neuro-electrical impulses. [64:17] But the point here is that there's [64:18] dopamine being squirted outside the [64:19] nerve cell. [64:21] Now, do you see this little baby right [64:22] here? [64:23] That's a vacuum cleaner. [64:25] And there are many of them on the [64:26] outside of this nerve cell, because the [64:28] job of that little pump, excuse me, [64:32] the job of that little pump is to vacuum [64:34] up all the dopamine once it's done its [64:36] job. And it's known as the reuptake [64:37] transporter. [64:39] And one of the genes I showed you, [64:41] called DAT1, builds and operates that [64:44] pump. [64:46] If you have a longer version of that [64:47] gene, you have too many pumps on your [64:50] nerve cell, [64:51] which means when this nerve cell fires, [64:53] the dopamine gets vacuumed right back up [64:55] again, [64:56] and it can't do its job, and it leaves [64:58] you in a state of too little dopamine. [65:01] Now, here's the really cool part. [65:04] People with ADHD have about 30 to 80% [65:06] more of these vacuum cleaners on their [65:08] nerve cells [65:09] in the basal ganglia. [65:11] And the other cool part is, you want to [65:13] know what Ritalin does to the brain or [65:14] Concerta when you take it? [65:16] It goes right there and it plugs up the [65:19] vacuum cleaner. [65:21] Like a sock at the end of a vacuum hose, [65:24] methylphenidate stops the transporter [65:26] from working. What does that do? Leaves [65:28] more dopamine outside your nerve cell. [65:31] Methylphenidate is a dopamine reuptake [65:34] inhibitor. [65:35] By the way, Strattera does the same [65:37] thing, but it does it for [65:38] norepinephrine, little bit for dopamine. [65:41] But nevertheless, we can now link a gene [65:43] to a problem in the brain and we can [65:45] link that problem to a drug. [65:48] You shouldn't be surprised to find that [65:49] that gene is a predictor of who is going [65:51] to respond to methylphenidate. [65:54] At least in the last three studies that [65:56] have looked at it. Which means at some [65:57] time in the future [65:59] when you go into an office, we may take [66:01] some of your saliva, genotype you, and [66:03] decide which drug to give you. Because [66:05] it's looking like genes will predict [66:07] your drug response. So, I would want [66:09] families to know that because that's [66:11] probably 5 years out, maybe. [66:14] Maybe more, maybe less. [66:16] But it's not just genes. Genes can [66:18] interact with your environment and [66:19] that's the purpose of this slide is to [66:21] show you very quickly paper published a [66:23] year ago by Richard Todd who died [66:25] suddenly shortly after publishing this [66:27] paper, one of our great psychiatric [66:29] geneticists in St. Louis. [66:32] What you are seeing here is children who [66:34] were genotyped to see whether or not [66:36] they had that DAT gene I just mentioned [66:38] and another risk gene. A plus means you [66:40] got the gene, a minus means you didn't. [66:43] Now, the top line, you see those Ys and [66:44] Ns? That's whether or not your mother [66:46] smoked during her pregnancy [66:48] with you. I want you to look all the way [66:50] over here, right side. [66:53] If you got both of these genes and your [66:54] mother smoked cigarettes, you are eight [66:56] times more likely to get this disorder [66:57] than anybody who had either one of those [66:59] causes. [67:01] That is a gene by toxin interaction. [67:04] And we have now found the same thing for [67:06] alcohol. [67:07] So, some ADHD is the result of both a [67:10] genetic predisposition of risk and the [67:12] fact that the mother may have consumed a [67:14] toxin [67:16] during the pregnancy of that child. [67:19] We know that genetic research is the [67:20] fastest moving area of research right [67:22] now in ADHD research. Out of all areas [67:25] of study, this is the one that is moving [67:27] so quickly. There are 100 articles a [67:29] year published on this subject alone, [67:31] right? [67:32] What can we expect from this rapidly [67:34] advancing study? We can expect to do [67:36] genetic testing to help with diagnosis. [67:38] We can expect to start subtyping you on [67:40] the kind of ADHD you probably have. [67:43] This is going to give us a better idea [67:45] of what you are at risk for because we [67:46] are already beginning to label and [67:48] detect that these genes carry risk for [67:50] other disorders, not just ADHD. For [67:53] instance, that DAT gene that regulates [67:55] that transporter is a predictor of [67:56] nicotine addiction. [67:59] We also know that these genes are going [68:01] to interact with each other and with [68:02] toxins in the environment, so that's [68:04] going to help explain why some people [68:05] got ADHD. And as you see here, it may [68:08] help in predicting drug response. And [68:10] notice we now have a paper just [68:12] published within the last year that [68:14] shows that whether or not your child [68:15] responds to behavior modification is [68:17] partly related to some of these genes. [68:20] Sensitivity to psychological treatment [68:22] may be in part genetically mediated. [68:26] Expect to see new drugs being developed [68:28] just for these genes. [68:30] And new psychosocial treatments may be [68:32] developed for certain genetic subtypes. [68:34] How cool is that? [68:37] I would want families therefore to leave [68:39] my office understanding that ADHD does [68:41] not arise out of the family or from [68:44] social causes. And especially to [68:46] understand that these things that are [68:47] very popular in the media and among many [68:50] uninformed parents [68:52] are not causes of ADHD for the most [68:54] part. Not the least of which is [68:56] television. [68:59] TV and video game playing are not [69:01] causing short attention spans. If I hear [69:03] this again in the media, I'm going to [69:04] throw up. [69:06] This is now taken as gospel. It is mere [69:09] folklore. There is no evidence that [69:11] human attention spans have changed at [69:13] all. What is changing is the amount of [69:15] media you can distract yourself with if [69:17] you so choose. [69:19] But it doesn't mean that this is causing [69:21] a short attention span. You've just got [69:22] more media to pay attention to, okay? [69:25] And of course, if you are easily [69:27] distracted and you don't like to read [69:29] for pleasure or sustained your attention [69:31] to things, you have a lot of choices out [69:32] there. [69:33] So, we do know that people with ADHD [69:36] watch television more, play video games [69:37] more, use the internet more, talk on [69:39] their cell phones more, text message and [69:41] Twitter more than other people do. [69:44] That doesn't mean these things caused [69:45] their ADHD. It's the other way around. [69:48] ADHD leads you to select these as [69:50] leisure activities [69:52] because they're so engaging. [69:54] We know that food additives don't cause [69:56] this disorder, but about 1 in 20 ADHD [69:58] children could be exacerbated by a [70:00] little bit of these things in their [70:01] diet, but it's a minor, trivial [70:04] scientific finding. You don't need to go [70:06] changing your child's diet as a means of [70:09] dealing with ADHD. And by the way, that [70:10] includes supplements like omega-3s, [70:13] which were recently found to benefit [70:14] less than 25% of ADHD. Only the SCT [70:17] inattentive type appeared to benefit. It [70:19] was modest. It was trivial. [70:22] Uh but it was kind of interesting. [70:24] But ADHD combined type did not appear to [70:26] benefit much from fish oil. [70:29] That's an nice randomized trial [70:30] published in Sweden just about 2 months [70:32] ago. And of course, we know that [70:35] child rearing has nothing to do with it. [70:37] So, I would want the family to [70:38] understand, here is a pie chart of the [70:40] causes of ADHD. 65% roughly genetic. All [70:44] the rest are biohazards that can provide [70:46] or produce brain injuries, and there is [70:48] no social factor on that list. [70:56] list. [70:58] Now, viewing ADHD as this neurogenetic [71:00] or neurobiologic disorder of [71:02] self-regulation brings with it some very [71:04] important insights. I would want you and [71:07] families who I counsel to understand. [71:10] Not the least of which is this one. [71:14] This is ADHD writ large. [71:19] It's always now. [71:21] ADHD [71:22] is [71:24] to summarize it in a single phrase [71:27] time blindness. [71:29] People with ADHD cannot deal with time. [71:32] And that includes looking back to look [71:34] ahead to get ready for what's coming at [71:36] you. [71:37] So, the individual with ADHD is kind of [71:38] living in the now. And wherever the now [71:40] goes, they are being pulled along by the [71:43] nose, wherever it goes. I'll give you an [71:45] example from our adult's clinic. It's [71:47] rather funny, but it wasn't to his wife. [71:50] This couple came into our office in [71:52] Massachusetts once and she said, "Let me [71:53] tell you what it's like living with this [71:54] guy because it's like having a fourth [71:57] child, actually. This is what happened [71:59] last weekend." [72:00] She says, "If you can't do something [72:01] about this, I'm leaving him." [72:04] Here's what happened. He went out to mow [72:05] the yard. [72:07] He wheeled the lawn mower out of the [72:08] garage and the tank was empty. So, he [72:09] reached for the fuel can. It was empty, [72:11] too. So, he threw it in the back of the [72:13] Ford Explorer and headed down to the [72:15] little Quickie Mart. [72:17] And while he was filling up the gas can, [72:18] his buddy pulls in in his Ford Explorer [72:20] and says, "You know, it's opening day on [72:23] the trout stream. [72:24] What do you say we go fish a little [72:25] bit?" [72:27] And so, the guy hops in his buddy's [72:28] Explorer and they go fly fishing. [72:31] And they are out for 6 hours. And then [72:33] they get thirsty and decide to stop off [72:35] at a pub for a beer. So, now they're at [72:37] the little local tavern. This is a true [72:39] story, by the way, because within an [72:40] hour the state police had found his car [72:42] still running and an open gas can at the [72:44] Quickie Mart. [72:47] And he finally wandered home at 4:00 in [72:49] the afternoon. [72:51] Do you see what happens? Doesn't matter [72:53] what your plans were, what your goals [72:55] were. The now is more compelling than [72:58] the information you're holding in mind. [73:00] And you will get pulled along [73:02] by the now. [73:04] You are time blind. [73:05] Because if we had to summarize [73:09] in a single sentence, what is the [73:10] purpose of the frontal lobe to humans? [73:13] It is to organize your behavior across [73:16] time [73:17] in anticipation of what is coming at [73:19] you. [73:20] The future. [73:21] So ADHD creates a blindness to time, or [73:24] technically, to be more accurate, [73:26] a near-sightedness to the future. [73:29] Can you say that again? [73:33] I can only be eloquent once. No. [73:38] This is extemporaneous. I'm not [73:40] Okay, ADHD, right? Is at its heart a [73:44] blindness to time, or technically, to be [73:46] exact, it is a near-sightedness to the [73:49] future. [73:51] Just as people who are near-sighted can [73:52] only read things close at hand, people [73:55] with ADHD can only deal with things near [73:57] in time. [73:59] The further out the event lies, [74:03] the less they are capable of dealing [74:04] with it. And this is why everything is [74:06] left to the last minute. [74:08] Because they only deal with last [74:09] minutes. [74:11] That's all they perceive, that's all [74:12] they deal with, that's all they organize [74:13] to. [74:14] And so their life is a series of one [74:16] crisis after another, all of which were [74:18] avoidable because people prepared. [74:20] And they didn't. [74:22] They weren't ready on time, in time, [74:24] over time with what they needed at that [74:26] time. [74:28] Note the word time, right? [74:30] So ADHD is destroying the timing and [74:32] timeliness of human behavior. That is a [74:34] very important thing for parents to [74:36] understand. Because while a 3-year-old [74:39] does not have to have a sense of time, [74:41] a 30-year-old does. [74:43] And one of the most devastating deficits [74:45] in adult life that ADHD produces is a [74:48] disruption in the fabric of time. [74:51] They can't cope with it as well as [74:52] others. [74:54] Now, this ability to organize across [74:56] time comes with the capacity to build [74:59] pyramids of behavior from little [75:01] behaviors [75:03] to the bigger behaviors above them to [75:05] the bigger goals above them. [75:07] All human behavior can be organized into [75:09] a hierarchy. Think about planning a [75:11] wedding. [75:12] Can you imagine the hierarchy you would [75:13] have to create? The decision trees and [75:16] when they would have to be done and when [75:17] you would have to book the church and [75:19] get the minister and get the flowers and [75:21] book the reception hall. And all of [75:23] those come with little sub routines like [75:26] picking up a telephone and calling your [75:27] minister, right? [75:29] It's the frontal lobe that allows you to [75:31] organize all of those toward the single [75:34] overarching purpose, [75:37] the wedding. [75:39] And that's what ADHD destroys. [75:41] People with ADHD cannot hierarchically [75:43] organize behavior. [75:45] And so they are accustomed to dealing [75:47] with behaviors in little fits and [75:49] starts. [75:50] But they can't glue those together as [75:52] well as others to create the bigger goal [75:55] to the bigger goal all the way up. [75:58] And that's why you see a short attention [75:59] span. It's not really a short attention [76:01] span. It's the inability to organize [76:03] behavior [76:04] across time into a hierarchy. [76:08] The ability to look ahead is called [76:09] intention. [76:11] So ADHD is actually IDD. It's intention [76:14] deficit disorder cuz it doesn't matter [76:16] what your intentions are, [76:18] you're not going to do them. [76:22] So, [76:24] oh, you can head out the door for school [76:26] in the morning and promise your mother [76:27] that you will not be put in time out [76:29] again. You really will get it right [76:31] today. [76:32] You will behave yourself. You will not [76:34] fight with the other kids. You will [76:35] finish your work and you mean it [76:37] sincerely. [76:39] But within an hour your mother's getting [76:41] the usual call that you're in timeout [76:43] and that you're disruptive and they need [76:45] to come and get you, right? [76:47] Notice what happens. Your intentions are [76:48] not the problem and it's not [76:50] insincerity. [76:52] It's the inability to organize around [76:53] those intentions. [76:55] So, ADD is really IDD. [76:57] Now, I want you to understand something. [76:59] Your brain can be split into two pieces. [77:01] The back part is where you acquire [77:03] knowledge. [77:04] The front part is where you use it. [77:06] The back part is knowledge, the front [77:09] part is performance. ADHD, like a meat [77:12] cleaver, just split your brain in half. [77:15] So, it doesn't matter what you know. You [77:17] won't use it. [77:18] You have what we call in psychology a [77:20] performance disorder. [77:22] Performance disorders have nothing to do [77:24] with skill. You have all the skills [77:26] other people your age possess, [77:28] but you can't use them. [77:29] Because you see, it's the executive [77:31] system where the rubber meets the road, [77:33] where what you know gets applied in [77:34] everyday what you do. [77:37] And ADHD is a disorder of doing what you [77:39] know. [77:40] It is not a disorder of knowing what to [77:42] do. [77:43] And that is a very important thing I [77:45] want families to understand as well. [77:47] Your child, unless they were raised in a [77:49] zoo or in a very impoverished area or [77:52] were adopted out of some far-fetched, [77:54] war-torn, undeveloped country, [77:57] has all the information and knowledge [77:59] that the other kids their age have. [78:02] What they can't do is use it. [78:05] It is the application of what you know [78:08] that this disorder robs you of. So, you [78:10] can be the smartest person on the planet [78:11] and you're still going to do some pretty [78:13] stupid things. [78:15] Because it's not what you know, it's [78:17] doing it. [78:19] So, I would want parents to understand [78:20] that that is a very profound disturbance [78:23] in a person's behavior, [78:25] but it arises out of neurology and [78:27] genetics and out of this is going to [78:29] come a very important view of what to do [78:31] about this disorder. [78:34] The first thing this is going to mean [78:38] is to stop teaching so many damn skills. [78:42] Because you're approaching this child as [78:43] if he's stupid, right? [78:45] Oh, he doesn't have any friends. I guess [78:48] he doesn't know social skills. So, we'll [78:49] take him down to the local clinic and [78:51] we'll enroll him in a 12-week social [78:52] skills camp about which we'll probably [78:54] pay $50 to $100 a session or we'll send [78:57] him to the Upper Peninsula, Michigan [78:58] where there's a nice summer social [79:00] skills camp that was advertised in [79:01] Chad's Attention magazine. There is. [79:04] It's probably a very nice camp. I don't [79:05] mean to belittle it. I'm just telling [79:07] you it will do no good, right? [79:12] Well, now let's understand something. I [79:13] might want to send a child to camp just [79:15] to have fun, right? [79:17] It's part of the quality of life. Go, [79:18] have a nice summer. But if I'm sending [79:20] you to camp [79:22] with the belief that you're going to [79:23] come back [79:24] a person with better social skills, you [79:26] are sadly mistaken, right? [79:29] So, we have got to stop putting all the [79:31] eggs in the skill training basket. [79:34] Because that's not where the problem is, [79:36] right? [79:37] We have got to spend more time changing [79:40] the point of performance. [79:43] The point of performance is where you [79:44] should be using what you know. [79:47] And you're not. [79:48] And the only way to treat a performance [79:50] disorder is to change that point. [79:52] This means that all treatment, if it is [79:55] going to work at all [79:57] must be at the point of performance. [80:00] The place in your life where you're not [80:01] using what you already know. And if the [80:04] intervention isn't done there, it's [80:06] useless. [80:08] That has been a major finding of the [80:09] last decade. The only treatments that [80:11] work are treatments that modify those [80:14] natural points in the environment where [80:17] the problems are occurring. [80:18] And if those aren't modified, nothing [80:20] done away from that site will do [80:22] anything. [80:24] So, you can do pull-out services. You [80:26] can go to summer or to social skills [80:29] camps. You can go to a ed. You can come [80:32] and see me for once a week for [80:33] psychotherapy. And everything I just [80:35] said will have no generalization or [80:37] maintenance. Won't go anywhere. Won't [80:38] even leave this room. Howard Abikoff [80:40] tells a beautiful story of the social [80:42] skills group he ran and on the day they [80:43] covered anger management and sharing, he [80:46] opened the door to the room and there [80:47] was a fist fight in the hall by the [80:48] elevator [80:50] over who was going to push the button. [80:54] So much for your anger management, [80:56] right? [80:58] Do you see what happens? You were [80:59] focusing on knowledge. Oh, let me teach [81:02] you how to share and cooperate and you [81:04] miss the point. [81:06] This is not information deficit [81:08] disorder. [81:09] All right, this is performance deficit [81:11] disorder. [81:13] So you got to change those points of [81:14] performance. If he has no friends on the [81:16] playground, you're going to have to do [81:17] something at that school. If you got [81:19] trouble with homework, it's the kitchen [81:20] table, honey. It's not my office. [81:23] We need to rearrange where the homework [81:25] is being done to help them show what [81:26] they know. As I've already said, this [81:28] point of view also then makes us look [81:30] very differently at psychopharmacology [81:32] as a form of neurogenetic treatment. [81:34] Now, everything I have just said could [81:36] be used by any parent to come up to me [81:37] and say [81:39] my child got thrown out of school [81:40] yesterday for some misbehavior. Would [81:43] you please go to school and get him [81:44] reinstated? He should not be held [81:45] accountable for these consequences, [81:48] right? Because after all, didn't you [81:49] just say it's a neurogenetic disorder? [81:51] So let me help you understand something [81:53] about what I've just said. [81:55] ADHD does not cause a problem with [81:57] consequences. [81:59] The problem is with time. [82:01] It was the delay to the consequence that [82:04] disabled you. [82:06] Which means that I'm going to do the [82:07] opposite of what this mother is asking. [82:10] Increase accountability, not decrease [82:13] it. Increase the frequency, immediacy, [82:16] the salience, and the timing of [82:18] consequences. People with ADHD need more [82:21] accountability, not no accountability. [82:24] In fact, this view of ADHD as an [82:26] executive disorder would tell you that [82:27] if you argue for no accountability, you [82:29] will make this disorder worse, [82:31] not better. [82:33] Because the problem is the delay, and [82:36] all natural consequences of any [82:38] importance are delayed. [82:43] What does that mean? We are going to [82:45] have to use behavioral treatments, the B [82:47] mod programs, the tokens, the charts, [82:48] the cards, the Smurf stickers, whatever. [82:51] What is their purpose? Their purpose is [82:53] not to teach. That is a misnomer, if you [82:56] will. [82:57] Their purpose is to sprinkle artificial [83:00] consequences into these delays in the [83:03] natural environment [83:05] in order to increase your [83:06] accountability. [83:08] So, they're not teaching anything. They [83:10] are making up for the accountability [83:12] deficit disorder. [83:14] B mod does not teach anything to ADHD [83:17] children, really. [83:18] What it does is improve the motivation [83:21] to show what you know. [83:23] By making you more accountable, more [83:25] often, around you, [83:28] you have less ADHD. By excusing you from [83:31] the consequences, you'll be more ADHD. [83:34] So, I want you to understand something. [83:35] There are two reasons why we would tell [83:37] you as a family to do behavior [83:39] modification. One is instructional. [83:42] This is why we teach families of [83:43] autistic and mentally children [83:45] behavior modification, to teach their [83:47] children things they don't know. [83:50] But the second purpose you would do B [83:52] mod for has nothing to do with [83:53] instruction. [83:55] It's motivational. [83:56] To make up for the motivation deficit [83:58] disorder that this disorder produces. [84:01] And so, if you do B mod for its [84:03] motivational value, you can't stop it. [84:06] Because if you pull it, you've pulled [84:07] the motivation. [84:09] If you do B mod for its instructional [84:10] purpose, you can pull it. Because once [84:13] they've acquired the skill, they'll use [84:14] the skill, and you don't have to worry [84:16] about it anymore. Now, do you see a a [84:18] contrast here? Most parents and nearly [84:21] all teachers I deal with believe that [84:23] B-Mod is for instructional value. [84:26] That's why we do it for ADHD, which is [84:28] why whenever you go into a school and [84:29] you try to teach a teacher to set up a [84:31] token system, the first question out of [84:33] his mouth [84:35] is how long do I have to do this? [84:37] When will he internalize the program? [84:39] And my answer is, never. [84:43] As long as he's in your class, you will [84:44] have to arrange artificial consequences [84:47] to replace the delayed ones. And if you [84:49] don't do that, he will not work for you. [84:52] So, I want you to think about token [84:54] systems and star charts and all behavior [84:56] modification as being equivalent to a [84:58] ramp that comes into this building. [85:01] That ramp is there to make people who [85:03] are physically disabled less motorically [85:06] impaired. [85:07] They can get into the building in their [85:09] wheelchairs or whatever other devices [85:10] they're using. [85:12] But would you ever say to such a person, [85:14] "After 30 days of entering this building [85:16] successfully using the ramp, [85:19] you know what I'm going to [85:22] You know the punchline, right? Can I [85:24] take the ramp away? Have they [85:26] internalized the ramp? Well, of course [85:28] not. [85:29] The ramp was never for teaching, right? [85:31] The ramp is a prosthesis. [85:35] A prosthesis is an artificial means of [85:38] reducing the disabling consequences of [85:41] your disorder. [85:42] It is not to train you up into anything. [85:44] No amount of using a ramp is going to [85:46] take the ramp away. [85:48] And no amount of B-Mod is going to take [85:50] the B-Mod away. [85:52] These individuals will always need more [85:54] frequent consequences around them than [85:57] will other people in order to perform at [85:59] the same level. It's just a general [86:01] corollary of ADHD. [86:04] So, what else have we learned about [86:05] ADHD? Well, if all treatment is at that [86:08] point of performance and if at that [86:09] point of performance, I'm trying to [86:11] arrange a prosthesis, a prosthetic [86:13] environment to reduce the impairment [86:15] from the disability, right? [86:18] Then it means that the caregivers are [86:19] the most important people in the [86:21] treatment plan. [86:22] The parents and the teachers. It is [86:24] their compassion for disabled people and [86:27] their willingness to make these [86:28] prosthetic accommodations [86:31] that is the heart of any successful [86:33] intervention. [86:34] And absent that compassion [86:36] no amount of quality in a good [86:38] professional or therapist is going to [86:40] change that. [86:42] You have to make those people [86:43] stakeholders. You've got to get them [86:44] invested. And if they're not, you're in [86:46] trouble. It doesn't matter how good a [86:48] clinician you are. [86:49] So it's best to look at ADHD, I would be [86:51] telling these families in my office, [86:53] like we look at diabetes. [86:55] Largely a chronic disorder. [86:58] And our goal is to manage it. [87:01] To create a reduction in the symptoms. [87:04] The purpose of which is the avoidance of [87:06] secondary harm. [87:08] We do not treat diabetes to get rid of [87:10] it. We treat it to prevent what happens [87:12] to you if you don't manage your diabetes [87:14] because you will go blind. [87:16] And your heart muscle will atrophy. And [87:17] you are at risk for sudden death. [87:20] And you will get gangrene. And you may [87:22] have your toes or fingers or other [87:23] appendages eventually amputated [87:25] if we do not manage your insulin levels. [87:28] That is what we try to prevent. [87:30] But no amount of treating diabetes is [87:32] ever designed to get rid of the [87:33] diabetes. [87:34] And I think ADHD is a very good analogy. [87:37] I think we manage ADHD to prevent the [87:39] secondary harms which I'm about to show [87:41] you. [87:42] We don't manage ADHD to get rid of it. [87:45] We manage it so that you don't [87:46] experience those more heinous [87:48] consequences. [87:57] So by changing the environment, you're [87:59] going to be able to help compensate for [88:01] the impaired executive abilities. [88:03] Now, the ADHD view of ADHD, the [88:06] attention view, does not tell you what [88:08] to do. [88:09] Does not not one whit does it guide me. [88:12] If you tell me somebody is inattentive, [88:14] I don't know what to do for them. What, [88:15] more coffee as I said? All right. [88:18] But if you tell me somebody has an [88:19] executive disorder, I will give you five [88:22] things to do immediately [88:24] at any point in performance. [88:28] Goodness, it's 3:30. Can I give you a [88:30] break right after this one? Okay. [88:33] Number one, [88:35] your child cannot stop and hold things [88:38] in mind. [88:41] So don't make them. [88:42] You need to use external physical forms [88:46] of information. Which means sticky [88:49] notes, signs, symbols, charts, cues, [88:52] reminders. [88:54] The issue here is not the what, it's the [88:56] why. [88:57] You must find a substitute for working [89:00] memory. [89:01] And that means something external. The [89:03] information, whatever it is that is key [89:06] for you to remember right here, right [89:08] now, needs to be outside of your brain [89:12] in the visual field. [89:16] You have got to externalize is the [89:18] phrase for that, [89:20] the information that other people are [89:22] holding in mind. It's what we are doing [89:24] after age 55 and women in perimenopause. [89:28] We are using a lot of sticky notes, let [89:30] me tell you. [89:31] Because I'm 59 years old and I already [89:34] have a little ADHD working memory [89:36] disorder as do most women. By the way, [89:38] it hits women harder than men. [89:40] But it hits us both. Nevertheless, we're [89:42] all running around with lists. [89:45] What was I doing? My wife even has a [89:47] digital memory recorder in her car so [89:50] that when she's out and she has to [89:51] remember something, she dictates it in [89:53] there so she can listen back and [89:55] remember what the heck she was supposed [89:56] to buy at the shopping center. [90:00] You see what we're all doing? Making up [90:02] for a working memory deficit. You need [90:04] to do the same thing with ADHD. [90:07] If you're an adult with ADHD, you should [90:08] not be going anywhere without a paper [90:10] journal in your pocket with a pen. [90:13] Because anything you agree to do or [90:15] anything others ask you to do is to be [90:17] immediately written in that journal, and [90:19] that journal is welded to your body. [90:22] That is your working memory. Use it. And [90:25] by the way, we find journals are better [90:27] than digital devices because they lose [90:29] the devices and they don't remember to [90:31] turn them on and they don't remember to [90:32] dictate into them. [90:34] So, as good as those things may sound [90:36] and as high-tech as they are, the good [90:38] old paper and pencil notebook seems to [90:41] do the job, okay? And if I were you, I [90:43] would even have it on a chain like a [90:45] motorcycle gang member has a wallet. [90:48] It is there from sunup to sundown. Man, [90:50] when you put your pants on, that is in [90:52] it all the time, right? [90:55] And now you have a working memory. [90:59] You have no internal clock. [91:01] So, if anything involves time, there [91:02] must be a timer. [91:04] There must be something physical outside [91:06] of you that signals the passage of time. [91:08] For young children, cooking timers are [91:10] great, but there are various other [91:11] devices including watches that beep [91:13] every 5 minutes and vibrators that you [91:15] can buy at the addwarehouse.com [91:17] that have digital timers built in and [91:19] you can set them to just vibrate in your [91:20] pocket every so often. I don't care what [91:23] the stimulus is. [91:24] This is the why, people, not the what, [91:26] right? [91:27] The why is you have no sense of time. [91:31] So, if I give you something that [91:32] involves time, I have got to give you a [91:34] timer. And if this extends more than [91:36] just a few minutes to a half hour, [91:38] you are going to need a day planner, a [91:40] Palm Pilot, or some other means of [91:42] keeping track of time. A [91:43] week-at-a-glance calendar is not a bad [91:44] thing, either. [91:46] But you are going to become timer and [91:48] calendar dependent, addicted. [91:51] So that you can organize your life as [91:53] well as other people who don't need to [91:54] rely on those things so much. [91:56] You cannot see the future coming at you. [91:58] So, if there is something you've agreed [91:59] to do over time, if this child has a [92:01] book report or a science project, you [92:03] are going to break that into baby steps [92:05] and do a piece a day. [92:07] You are not going to point at the future [92:08] and keep harping about summer reading. [92:10] Have you done your summer reading? We've [92:12] got that book report that's due next [92:14] week. Have you done that? Right? No, we [92:16] are going to take the book report and [92:17] you are going to read three pages today. [92:19] You are going to write four sentences [92:21] today and I will give you 15 tokens [92:23] right now. And that's how we're going to [92:24] get this done. [92:26] We are going to break the future into [92:27] pieces and do a piece a day. And stop [92:30] pointing at the future because you can't [92:32] organize to the future. That is your [92:34] disability. That's like going on to an [92:35] inpatient unit at the psychiatric [92:37] hospital saying, "God, these people [92:39] hallucinate around here. What's going [92:41] on?" It's an inpatient unit. They're [92:42] schizophrenics. What did you think? [92:44] Right? [92:45] You should not be shocked that you have [92:47] to break things down for people who have [92:48] a time management disorder. [92:50] And so, you should do it for people with [92:52] ADHD as well. Break the future into [92:55] pieces. By the way, what does ERO mean [92:56] on this? [92:58] It means that the future comes at you in [93:00] three pieces. The events that are coming [93:02] towards you, [93:03] the responses you prepare, [93:05] and the consequences, the outcomes of [93:08] what you're doing. [93:09] ERO. So, here's the lesson I would want [93:11] this family to understand. If those E's [93:14] and R's and O's are kept close together, [93:16] you don't need a frontal lobe. [93:18] And ADHD people can do them. That's a [93:20] video game. [93:22] But the minute you stretch these things [93:24] apart with time, like a book report, [93:27] you've got to read this book. Your [93:29] report's due in 30 days. It'll take a [93:31] week to grade all the papers. I just put [93:34] a month between the E and the R and a [93:36] week between the R and the O. And if you [93:37] have ADHD, you're disabled, big time. [93:41] So, the solution is to get the E's, R's, [93:43] and O's back together. And that means [93:44] baby steps, little ERO bridges across [93:47] time. [93:48] And that's how you would do a future [93:50] assignment. [93:51] Now, how are we going to deal with the [93:53] fourth executive function deficit, the [93:56] emotional motivational one. [93:58] It means all motivation is external. We [94:02] already talked about this. [94:04] Which means I am going to have to have [94:05] something in it for you if you are going [94:08] to persist. So, stop whining. Stop [94:11] complaining why you have to offer [94:13] something for this child to work. [94:16] The reason you don't offer it to other [94:17] children is they have internal [94:19] motivation. ADHD children do not. [94:22] So, don't worry that by paying them [94:24] tokens for doing their reading or their [94:26] assignments you're somehow going to [94:27] pervert a sense [94:30] of doing things for their own reward or [94:33] value. Being a good citizen for the sake [94:36] of being a good citizen. That is not [94:38] going to work for ADHD. The ADHD child [94:40] is Donald Trump incarnate and there [94:42] better be a deal. [94:45] And if there is no deal, it ain't [94:47] getting done. [94:49] So, to borrow a phrase from Stephen [94:50] Covey, please think win-win. [94:55] A win for them, not just a win for you. [94:57] And that means you are going to have to [94:59] drop in the points, the tokens, the [95:00] privileges, the sex, the drugs, the [95:01] money, and the car. [95:06] My medications are wearing off, I think. [95:10] The last executive function, which is [95:12] mental play. It's the ability to [95:14] manipulate the contents of your mind [95:17] in creative ways to invent multiple [95:20] possibilities. Very hard for these [95:21] people. This is why they can't do mental [95:23] arithmetic as well as others. It's why [95:25] they can't do digit span backward as [95:26] well as others. It's why they have [95:27] trouble playing the little musical game [95:29] Simon. [95:30] Working memory, but if you can't hold [95:32] things in working memory, then you can't [95:34] manipulate your working memory. And [95:36] that's where the source of planning and [95:37] problem-solving are coming from. So, [95:39] what do we do? Well, we're going to take [95:40] the same word we did before. [95:41] Externalize. We're going to make [95:43] problem-solving manual. [95:45] Physical. [95:47] You get to do it with your hands. So, [95:48] let's take math problems. I'm going to [95:50] give you a bunch of marbles, [95:52] a number line, [95:54] an abacus, [95:56] or a calculator, but the first three [95:58] would suffice, right? You're going to do [95:59] math with your hands, the way it [96:01] originally was done. [96:03] I'm not going to ask you to do [96:04] arithmetic in your head. You're going to [96:05] find that to be difficult. You need a [96:06] crutch. You need an external [96:09] prosthesis to help you with your math. [96:12] Now, what if this is a verbal problem or [96:15] task, like you've got to write a story [96:17] or an essay or something? I'm going to [96:19] give you a stack of 3 by 5 file cards, [96:21] and I want you to sit down and put your [96:22] mind on dump. [96:24] I want you to think of any idea you can [96:25] come up with that has to do with this [96:27] subject. Go. I want a thought per card. [96:30] I don't care what order, I don't care [96:31] what sequence, just let your mind run [96:33] wild. [96:34] But just give me a thought a card. [96:36] Now, I'm going to take your cards and [96:38] reorganize them, and now we've got them [96:40] physical, and now we can create the [96:41] story and the plot line. [96:44] And if you do this on a laptop computer [96:46] in Word, you can even move it around and [96:48] spell check and cut and paste and do all [96:49] that neat stuff because it's now [96:50] external. Your ideas have become [96:53] physical, and that's the secret here. [96:55] Make the mental information physical in [96:58] some way, [97:00] and then they might be able to do it. [97:02] This may explain why more people with [97:03] ADHD wind up in the trades than in any [97:06] other professions. [97:08] I used to think it was because the [97:09] trades don't require as much advanced [97:11] education. [97:12] I now think it's probably also the fact [97:15] that it's manual. [97:16] Whether you're a carpenter, a plumber, a [97:18] landscaper, a bricklayer, a tuner or [97:20] electrician, tuner of pianos I meant to [97:22] say or others, [97:24] you are doing something manual, and that [97:27] may matter. We'll see. [97:29] Lastly, ADHD rarely occurs alone. ADHD [97:32] children are at risk for all of these [97:34] other disorders. [97:36] In fact, 80% of ADHD children and adults [97:38] will have one of these other disorders, [97:40] and 50% will have at least two of these [97:42] other disorders. So, seeing ADHD by [97:44] itself is very rare. Seeing ADHD link up [97:47] with a few other disorders is not rare, [97:49] It's common. And so I would want [97:51] families to understand that we may have [97:53] to treat other disorders, not just the [97:55] ADHD. The ADHD may be one problem, and [97:58] it may be the biggest, most impairing [97:59] problem, [98:01] but it's not the only problem that we [98:02] may have to deal with. And on that note, [98:05] we are going to give you a 10-minute [98:07] break. You will be called back at 10 [98:09] minutes to 4:00 [98:10] because I got 15 other ideas I want to [98:12] share with you. [98:15] Oh. [98:16] Welcome. Thank you. [98:18] I'll talk to you. [98:20] Thank you so much. [98:28] So, let me show you what untreated ADHD [98:30] is likely to have associated with it [98:33] over time. [98:35] And this is from my own longitudinal [98:36] study and others. [98:37] First of all, school is the major area [98:40] of impairment, but we all know that. [98:41] They're more likely to be held back in [98:42] school. A third of them quit high school [98:44] without finishing. Only 5 to 10% ever [98:47] finish college. [98:48] So, undereducation is a classic ADHD [98:52] impairment. But that, of course, is [98:54] going to lead to problems in the [98:55] workplace. And you can see the ones that [98:57] we've identified here. [98:59] And it's also going to lead to problems [99:01] in driving because we know the single [99:02] biggest cause of auto accidents in the [99:05] North American population is in-vehicle [99:07] distraction. [99:08] And this is a distractibility disorder. [99:11] So, no surprise, they're going to have [99:13] problems. But they have problems at all [99:14] levels of driving, as you see here. More [99:17] speeding tickets, more car accidents, [99:19] multiple accidents, worse accidents. And [99:22] as a result, they're going to have their [99:23] licenses suspended three times more [99:25] often than other people. [99:27] So, driving becomes a major problem. In [99:29] fact, as has been said, there is no [99:31] disorder that interferes with driving to [99:33] the degree that ADHD does. [99:35] So, this is a major area of impairment, [99:37] which is why your Canadian Pediatric [99:39] Association has now recommended that if [99:41] pediatricians see a teenager who's about [99:43] to start driving and they have ADHD that [99:45] is at least moderate in severity, [99:48] you need to medicate them while they [99:50] drive. I would say that that should be [99:51] the case for nearly all clinically [99:53] referred people with ADHD. Because if [99:56] they're clinically referred, they [99:57] probably at least have it to a moderate [99:58] to a severe degree. Why is that? Because [100:01] you can kill yourself. [100:02] And you can kill other people as well [100:05] with a motor vehicle and we don't want [100:06] to see that happening. [100:09] Now, in addition to those, there are [100:10] some other areas of impairment, not the [100:12] least of which is managing money. As [100:14] they move away from home, as they get [100:15] jobs, as they get credit, as they borrow [100:17] money, as they take out car loans, [100:19] we start to see them having troubles [100:21] paying their bills, paying them on time [100:23] so that they get the utilities turned [100:24] off, their cars repossessed, their [100:26] credit rating is terrible because you've [100:28] given a very impulsive person credit. [100:31] There's no bill on that. [100:33] No. [100:38] Boy, could we use that these days, huh? [100:41] Everybody working for AIG would go on [100:44] this. [100:46] But this is an area that very few people [100:48] took a look at, but duh, I mean, it [100:51] makes perfect sense when you phrase it [100:53] as a disorder of self-control given a [100:55] credit card. [100:56] And now we can understand what's going [100:58] to happen with the the credit problems. [101:01] So, obviously they need more [101:02] accountability in their financial [101:03] management. Social problems are going to [101:05] continue into adulthood for many, though [101:07] not for all of them. They often as [101:09] adults describe themselves as having [101:11] trouble sustaining long-term [101:12] relationships, particularly dating and [101:14] marital relationships [101:16] uh or partnering with people [101:18] uh and we will see that they do [101:19] experience divorce at a higher rate than [101:22] other people do because of these [101:23] difficulties. [101:25] An area now that has been studied more [101:27] in detail um is the area of sexuality. [101:30] We do not find more sexual disorders. [101:32] So, pedophilia, transvestism, or other [101:34] difficulties are not more common [101:37] in this population. What we do find, as [101:39] you would guess knowing an impulsive [101:41] person, is greater risky sexual [101:44] activity. [101:46] Starting to have intercourse a year [101:47] earlier than other teenagers, having [101:49] more partners because they don't stay in [101:51] dating relationships as long, not using [101:53] contraception because they're so [101:55] impulsive. [101:56] All of which leads to a tenfold increase [101:58] in teenage pregnancy. We now know in [102:00] fact there is no better predictor of [102:03] adolescent pregnancies than ADHD. [102:06] In my study, 32% of the boys had [102:08] fathered a child by 19, 68% of the girls [102:12] had been pregnant at least once before [102:14] 19 years of age. [102:16] So, this is a disorder that predisposes [102:18] to becoming a parent very young. And by [102:21] the way, we saw the same thing in the [102:22] parents of these kids as well. And [102:24] that's because their parents have ADHD [102:26] also. ADHD in adults leads to earlier [102:29] parenthood than the general population [102:32] would be experiencing. And then of [102:34] course, notice a fourfold increase in [102:36] sexually transmitted disease. [102:40] So, we have a group of individuals who [102:42] if not treated are going to be [102:44] experiencing impairments in every major [102:46] life activity we have studied. There is [102:48] no domain of life free of the influence [102:50] of ADHD that we have yet identified. [102:54] Which is why we argue now for longer [102:56] term treatment across the week, across [102:58] the year, and especially through [103:01] adolescence. Because most children if [103:03] they're on medication, it's for 3 years [103:05] or less. And if they're in treatment [103:07] programs, it's only for a few years or [103:08] less. And what we have found in these [103:10] studies is that childhood only treatment [103:12] was useless. Useless in terms of [103:14] changing the life course of these [103:16] individuals. Now, to understand why [103:18] these disorders, why these impairments [103:21] that is, would continue into adulthood, [103:23] we need to go back and understand that [103:25] it's a disorder of self-regulation. [103:28] And it's a quantitative deficit. So, [103:30] that begs the question, how far behind [103:33] is this child? And so, the rule that I [103:35] have taught for years in our clinics to [103:38] families, and it remains a very good [103:40] rule of thumb, [103:42] is the average ADHD child is 30% behind [103:45] their age. Some are even more, but on [103:48] average across all ADHD children, it [103:50] looks to be about 30%. So, here's what I [103:52] want parents to do. If your child is 10, [103:55] he has the self-control of a 7-year-old. [103:58] That is how long he can persist. That is [103:59] how long he can remember. That he can go [104:02] without supervision. [104:04] His ability to self-organize [104:06] is that of a 7-year-old. Now, what would [104:08] you do for a 7-year-old? [104:10] How would we arrange homework? [104:12] What else would we be doing around [104:14] chores, around social functioning, [104:16] around independence from parents? [104:18] You wouldn't be doing as much as you [104:19] would with a 10-year-old. You would not [104:21] allow as much responsibility, as much [104:23] freedom, as much independence. [104:26] So, I want parents to be lowering their [104:29] expectations to the child's executive [104:32] age. [104:34] What is his self-regulatory age? It's [104:37] 30% younger. All right, that's what you [104:39] can expect. And if you are expecting [104:41] more than that, you're my problem. [104:44] Because you're causing the conflict. You [104:46] are like a parent of a dyslexic child [104:48] demanding normal reading. You are like [104:50] the parent of a mildly child [104:52] demanding normal self-sufficiency, [104:55] normal cognitive development. You're my [104:56] problem, because you just don't get it. [105:01] So, I want you to get it. It's a 30% [105:04] lag. That's where they're at. That's [105:06] what you can expect. If you're asking [105:08] for more, you're going to have to do [105:10] something [105:11] to rearrange that environment [105:13] to allow them to show what they know. [105:16] But if you don't do anything, they're [105:17] going to be about 30% behind. So, what [105:20] does it mean at 16 about giving kids a [105:22] license? [105:24] Are you out of your mind? All right. [105:27] You just gave an 11-year-old a motor [105:29] vehicle. [105:30] And you're shocked to see the driving [105:32] consequences, right? [105:34] You may have an 18-year-old who's one of [105:35] the few that's going to go on to [105:37] college. [105:38] He's 12. That's his executive age. How [105:41] would you have to design a campus if [105:43] 12-year-olds were showing up to go to [105:45] school? [105:46] Those exactly are the accommodations you [105:48] have got to make on that campus for this [105:50] person. [105:51] Pretend they're 12. [105:53] More hand-holding, more accountability, [105:55] more reporting to student services. [105:58] You're going to get more curriculum [105:59] materials. You're going to study in [106:01] groups with older, more competent [106:03] students. You're going to be in a [106:04] substance-free dorm. And you are going [106:06] to be accountable to student services [106:08] four times a day for the work you're [106:09] doing. [106:11] In other words, we're going to treat you [106:12] like you're 12, right? And then you [106:14] might just get through. [106:16] But what do we do now? We send you off. [106:17] You fail the first semester, and [106:18] everybody wrings their hands of, "Oh, [106:20] what are we going to do? We're going to [106:21] have to change the campus. We're going [106:23] to have to change the environment to [106:25] suit the executive level, not the [106:27] chronological level." So, you need to [106:29] understand the 30% rule because it [106:31] applies to everything. [106:33] I have a 14-year-old daughter with ADHD. [106:35] Should she be allowed to babysit? Are [106:37] you crazy, right? [106:39] This is a 9-year-old being given care of [106:42] an infant. No way. I don't care she [106:45] finished the Red Cross babysitting [106:47] course. I don't care if she's got a [106:48] certificate. [106:49] We don't let 9-year-old attend [106:52] 3-month-old babies unsupervised. [106:56] And that is her executive age. [106:59] You think this is hypothetical? We have [107:01] legal cases of people even into their [107:04] late teens and 20s [107:06] who have killed babies [107:08] out of anger, out of impatience, out of [107:10] immaturity, out of not knowing what to [107:13] do when the baby got upset. And then [107:15] their emotion comes to the forefront. [107:18] So, we don't want to go there. [107:19] So, you should be looking at all of [107:21] these avenues of independence and [107:24] applying the 30% rule to them. And [107:26] that's what you allow. And if you are [107:28] going to give them more, you better be [107:30] doing something to see that they can [107:31] handle it. [107:33] Okay, we want you as a parent to [107:35] understand that every treatment plan has [107:37] to have these four components. [107:39] Or it's not going to work. Component [107:41] number one, you got to get a good [107:43] evaluation. You have got to see an [107:46] appropriate knowledgeable professional. [107:48] It doesn't matter whether it's a [107:49] developmental pediatrician, a child [107:51] psychiatrist, a child psychologist, or a [107:53] behavioral neurologist, as long as they [107:55] are well trained and knowledgeable about [107:57] ADHD. That's the trick. It's not the [108:00] degree. It's the knowledge. It's the [108:02] training. It's the experience. Do they [108:04] see lots of ADHD kids and families or [108:06] adults? [108:08] So, we need an evaluation because 80% of [108:10] these people have another disorder. And [108:12] that's going to need to be treated as [108:14] well. [108:15] Next, families need to educate [108:17] themselves. We'll talk more about that. [108:19] But, you need to become an expert about [108:22] ADHD or you're not going to know how to [108:23] deal with it. Attending this afternoon [108:25] has been a big step in that direction. [108:27] Third, you need to understand that [108:29] medication is the most effective thing [108:30] we have. And that doesn't matter to me [108:33] whether you like that or not. That is a [108:35] statement of fact. [108:37] We have no more effective interventions [108:39] than these medications, which is why in [108:40] the last decade we have moved them up in [108:42] our priority of using them. It used to [108:45] be that we would try everything else [108:46] under the sun first. And only if they [108:49] failed, go to medication. Well, guess [108:51] what? 80% of them failed and we went to [108:52] medication anyway. And we should have [108:54] started with it to begin with because it [108:56] would have made them more amenable and [108:57] more susceptible to the other [108:58] psychosocial educational programs we [109:00] were trying to do. [109:02] So, don't be surprised to learn that up [109:04] to 80% of ADHD children will be on [109:06] medication at some time in their [109:08] developmental period, whether that is [109:10] childhood or adolescence. Because there [109:12] are times and places where you cannot [109:14] institute a psychosocial treatment. If [109:16] your child is driving home from the [109:18] homecoming last night, which was over at [109:21] the Delta hotel, by the way, I checked [109:22] in and there's a prom going on, [109:26] you can't be there handing out tokens [109:28] for following the speed limit. You know, [109:29] this is idiotic to think that behavioral [109:31] interventions are as good as [109:33] medications. They're not. [109:35] Where they're done, when they're done, [109:36] they're good. But there are places where [109:38] they can't be done. [109:40] And now what do we do? The medications [109:42] fill those gaps. [109:45] So, that's why we use them and that's [109:47] why you're seeing medication on the [109:48] increase in both of our countries. And [109:51] it is completely rational to do so. [109:54] Then we make accommodations. [109:57] That's what I meant by altering the [109:58] points of performance using those five [110:00] strategies we talked about, [110:02] externalizing information. You need to [110:04] create prosthetic [110:06] devices in these places to help them [110:08] show what they know. [110:15] So then, as a parent, now that you know [110:17] ADHD and you know that it's a more [110:18] profound and a more impairing disorder [110:20] than we once thought, what can you do? I [110:22] want you to take three roles and you can [110:24] read about these in my book Taking [110:25] Charge of ADHD. The first role every [110:29] parent should play [110:30] is to become a scientific parent, which [110:32] means make yourself an expert. I want [110:34] you knowing as much as the professionals [110:36] know. [110:37] So, you should be reading widely because [110:39] truth is an assembled thing. It doesn't [110:41] come from a single website or source. It [110:43] comes from integrating across those and [110:46] seeing the reliable information that [110:48] keeps showing up across the various [110:50] sources that you're reading. [110:52] So, whether you go to chadd.org or [110:54] add.org or catac.org or the other [110:57] websites, [110:58] read, learn, become an expert, know as [111:00] much as you can. Just like a family of a [111:02] diabetic child needs to know diabetes [111:04] inside and out if they're going to [111:06] appropriately cope with and compensate [111:08] for that child's diabetes. [111:10] And then, just like a scientist, you are [111:11] going to have to experiment. There are [111:13] hundreds of things that you can do, but [111:14] they don't all work for every child. So, [111:17] we have to test, revise, test, revise. [111:19] Try it. Does it work? If it doesn't, [111:20] let's move on to something else. [111:22] So, there's a test revise process about [111:24] raising an ADHD child. You're not going [111:26] to get it perfect out of the gate. And [111:28] what worked for one parent may not work [111:30] for your child. And somebody may be on [111:32] Concerta, but your child's going to need [111:33] Adderall or Vyvanse or Strattera. [111:37] And the same dose that worked for one [111:38] may not work for the other. It is a [111:40] process of experimenting and letting [111:42] your child show you which of these [111:44] things may work for them. [111:47] So, be a experimenter. I tell that [111:50] because parents come in and they try the [111:51] token system and it didn't work and they [111:53] try time out and you know, expecting [111:55] that the first thing out of the gate is [111:56] going to be successful and it isn't [111:58] always so. You got to keep trying. And [112:01] then, I want you to become very [112:02] skeptical. There was a lot of junk [112:05] knowledge out there, especially on the [112:07] internet. You type ADHD into Google, [112:09] which I did this morning, 14 million [112:12] replies. [112:14] There is no way a parent can search that [112:17] for the diamond in the dung heap. So, [112:21] I want you to become very skeptical. If [112:25] you are not hearing this information [112:27] reliably across different sources, it [112:29] probably isn't true. And if it sounds [112:32] too good to be true, just like financial [112:34] planning, it probably is. All right. [112:37] So, be careful out there. There are [112:39] magnetic mattresses, there's copper [112:41] bracelets, there's ginkgo biloba, [112:43] there's omega 3-6's, there's [112:45] antioxidants like Pycnogenol. There is [112:48] so much junk out there. There's a clinic [112:49] in Las Vegas that will diagnose your [112:51] whole family and give you chips to spend [112:53] at the casino. [112:55] You know, [112:56] maybe that works. I don't know, right? [112:59] But, you get the point, all right? There [113:01] is so much trash out there that it's [113:04] hard to sort it out. So, that's why you [113:07] really need to have your skeptic hat on [113:09] whenever you're reading anything and [113:11] you're looking for reliable information [113:14] across sources, and then you will filter [113:17] out the gems. [113:19] The next rule, you need to become an [113:20] executive parent. You need to stop [113:22] whining, suck it up, man up, and own [113:24] this disorder in this child. This is the [113:27] hardest thing for families to do. They [113:29] learn about it, they read it, but they [113:31] don't necessarily own it. There is this [113:33] sort of, if you will, reticence that [113:36] they have internally that I see from [113:38] time to time where they always hold out [113:41] this hope that there's some silver [113:43] bullet out there, usually on the [113:45] internet, that if they just tried that, [113:48] all the problems would be solved, we [113:49] could give this up, he'd be normal, and [113:51] let's get on with life, right? [113:53] And I wish there was the silver bullet, [113:55] but there isn't. So, we tell this to [113:57] ADHD adults as well. It's one thing to [113:59] know ADHD, it's another thing to own [114:02] your ADHD and to make it a part of who [114:05] you are. It's not all of who you are. [114:08] You may be a gifted artist, you may be a [114:10] comedian, you may be a scientist, you [114:11] may be a physician. None of that has to [114:13] do with ADHD. [114:15] ADHD predisposes to no gift, but you do [114:19] have other gifts and other talents at [114:20] which you are good at. [114:22] So, I want you to embrace ADHD as part [114:25] of who you are, but not all of who you [114:27] are. ADHD is a small set of traits out [114:30] of the more than 400 that you were [114:32] blessed with. [114:34] So, you may be good at lots of other [114:35] things. Let's find those other things [114:37] because they're going to have to [114:38] compensate [114:39] for what your ADHD is dragging down, but [114:42] don't ever attribute those other [114:43] successful enterprises to your ADHD cuz [114:46] it just ain't so. This is no gift, [114:50] but it doesn't mean you don't have other [114:51] talents that we could use to compensate [114:53] for it. Whether you're a good athlete, [114:55] whether you're Michael Phelps, whether [114:57] you're a good comedian, whether you're [114:58] Ty Pennington on America's Extreme Home [115:00] Makeover who loves to tear down houses [115:02] since he was a kid, and now he does it [115:04] for a living, right? [115:06] All of these are ADHD adults, right? [115:09] But, their giftedness is not due to [115:11] their ADHD. It was something they found [115:14] that they did well that could compensate [115:17] for the problems that their ADHD had [115:19] caused. [115:20] So, becoming an executive parent, like [115:22] becoming an executive adult with ADHD, [115:24] means part of it is I own the disorder. [115:27] My child has this disorder. Cuz until [115:29] you own it, you will not advocate for [115:30] this child. [115:32] And you have got to get out there and [115:33] advocate and not let other people take [115:36] charge of your child. That's why I [115:37] called my book Taking Charge of ADHD. [115:40] Because too many times I went to school [115:41] conferences and I saw parents sit [115:43] intimidated [115:45] by the degrees sitting around the table [115:47] and saying nothing about what was being [115:49] said in that meeting. [115:52] And I have to remind parents, these [115:53] people work for you. You are the [115:55] taxpayer. This is your child. You should [115:58] be running this meeting. I want you [115:59] coming in with a pad and a tape player, [116:02] and I want you turning it on, and I want [116:03] you saying to people, "I'm not going to [116:05] be able to take all the notes I want. [116:06] I'm going to record this meeting. Now, [116:08] let's talk about my son. Let's start [116:10] with you. You're his homeroom teacher. [116:11] What do you think? What's going on [116:12] here?" [116:13] If you have to, run the damn meeting. [116:15] And if somebody says something you don't [116:17] understand, like your child's [116:18] Woodcock-Johnson psychoeducational IQ [116:20] was, you are going to stop this meeting [116:23] cold in its tracks. I don't know what [116:25] you're talking about, right? [116:27] Because you're going to see a lot of [116:28] jargon tossed around by school [116:29] professionals. Part of it's just showing [116:31] off. [116:33] So, stop it, right? If you don't [116:35] understand it, you advocate. And you [116:37] can't advocate if you don't know what [116:38] they're talking about. And then the [116:40] final decisions are always yours, [116:43] whatever the list of recommendations [116:45] are. Because sometimes the [116:46] recommendations don't fit your child. [116:48] This is just a list of recommendations [116:50] that apply to ADHD plain vanilla, and [116:52] you may not have plain vanilla. [116:55] So, you're going to have to look at [116:56] those. You know your child better than [116:57] anybody else and you will pick and [116:59] choose from those the ones you believe [117:01] are most suitable to your family, to [117:03] your child, to your values, and so on. [117:05] But you run the meeting. And you don't [117:09] sign off on anything that you are not [117:10] comfortable with. I love parents who [117:13] come in and give me grief. I do not like [117:16] parents who come in and sit like a bunch [117:17] of milk toast sitting in an office and [117:20] just listening, listening, listening and [117:22] not asking questions and not advocating [117:24] and not telling me, "I don't think [117:25] that's going to work. His grandparents [117:27] are not going to buy Concerta. They're [117:28] going to take us to court for child [117:30] abuse. You got to help me with that." [117:32] That's a true story and that comes from [117:33] my nephew. [117:35] So, consequently, families need to speak [117:37] up. How do I know that your grandparents [117:39] are resistant to medication and that [117:41] they will make your life miserable if [117:43] you don't tell me? [117:44] Okay, now I can tell you how to help the [117:46] grandparents. [117:47] But you see, if the parent doesn't talk [117:48] up, I don't know. [117:50] I can't help you cope with that. [117:52] Rule number two, advocate. [117:54] Number three, if you haven't read [117:56] Covey's The 7 Habits of Highly Effective [117:58] People, you better. In fact, the better [118:00] book is The 7 Habits of Highly Effective [118:02] Families [118:03] because we have found that more than any [118:05] other families, families raising [118:07] disabled children, really need to learn [118:10] and utilize these. [118:12] Covey has at the back of the book a [118:13] diagram that looks like an hourglass [118:15] that has all seven principles built into [118:18] these two upside down triangles. [118:21] Photocopy it and tape it to your [118:22] bathroom mirror. [118:24] When you are putting on your makeup or [118:25] shaving in the morning, I want those [118:27] seven habits in the corner of your [118:28] visual field. That is your morning [118:31] reminder to try to get it right. [118:35] I do that. You should do that. And I [118:37] didn't raise ADHD children, but these [118:39] are very good principles [118:41] for interpersonal relationships and [118:43] especially if you have a disabled child. [118:46] So, if you're not familiar with it, [118:47] these are the seven principles. You can [118:49] read more about them. [118:51] Now, once you have adopted these three [118:53] roles, there is another role I would [118:55] like you to assume. And this I think [118:57] just paints the whole picture. This is [118:59] sort of the background canvas on which [119:01] you paint the rest of this portrait. [119:04] You need to understand something that [119:06] parents these days have long since [119:08] forgot and they're going to have to [119:09] relearn again. Your grandparents knew [119:12] this, but today's generation of parents [119:14] doesn't seem to. [119:15] And that is you do not get to design [119:18] your children. [119:19] Nature would never have permitted that [119:21] to happen. [119:22] Evolution would not have allowed a [119:24] generation of a species to be so [119:26] influenced [119:28] by the previous generation. It hasn't [119:30] happened and it doesn't happen and it [119:32] especially doesn't happen in children. [119:35] You do not design your children. And yet [119:37] we have the Mozart effect, the belief [119:39] that if I play classical music to my [119:41] uterus when I'm pregnant, I'm going to [119:42] have a genius. The fact that if I can [119:45] just put enough crib toys over his crib, [119:48] he is going to have all these neurons [119:49] exploding with synapses and be a [119:52] brilliant mathematician. You don't get [119:55] that degree of power, right? [119:58] Does that mean stimulation doesn't [120:00] matter? No, it means a stimulation [120:01] environment is better than a deprived [120:03] environment, but it doesn't mean that [120:05] the more stimulation you add into the [120:07] environment, the better it gets. It's a [120:08] threshold. There is enough stimulation [120:10] that every normal brain needs to develop [120:12] and once you're past that, which 98% of [120:14] you are, [120:15] the rest of it is out of your hands. [120:18] But this idea that if a little bit is [120:20] good, a ton of it must be better is a [120:22] uniquely North American perspective, [120:24] right? Believe me, the French don't look [120:26] as kindly on their children as we do, [120:28] right? [120:30] Uh that's another story for another day. [120:36] So, what we have learned in the last 20 [120:39] years of research in neuroimaging, [120:41] behavioral genetics, developmental [120:42] psychology, neuropsychology can be [120:44] boiled down to this phrase. [120:47] Your child is born with more than 400 [120:50] psychological traits that will emerge as [120:54] they mature, and they have nothing to do [120:56] with you. [120:59] So, the idea that you are going to [121:00] engineer personalities and IQ and [121:02] academic achievement skills and all [121:04] these other things [121:06] just isn't true. Your child is not a [121:09] blank slate on which you get to write. [121:12] If you would like to read more about [121:13] this, please read Steven Pinker's book, [121:15] The Blank Slate, [121:17] which is a review of all of this [121:18] information for parents and why it isn't [121:20] true. [121:21] The better view is that your child is a [121:23] genetic mosaic of your extended family, [121:27] which means this is a unique combination [121:30] of the traits that run in your family [121:32] line. [121:34] I like the shepherd view. You are a [121:36] shepherd. You don't design the sheep. [121:39] The engineering view makes you [121:40] responsible for for everything, [121:42] everything that goes right and [121:43] everything that goes wrong. This is why [121:45] parents come to us with such guilt, more [121:47] guilt than we've ever seen in prior [121:49] generations, because parents today [121:51] believe that it's all about them and [121:53] what they do. And if they don't get it [121:56] right, or if their child has a [121:57] disability, they've done something [121:59] wrong. [122:00] When in fact the opposite is true. This [122:02] has nothing to do with your particular [122:04] brand of parenting. [122:06] So, I would rather that you stop [122:08] thinking yourself as an engineer and [122:09] step back and say, "I am a shepherd to a [122:12] unique individual." [122:14] Shepherds are powerful people. They pick [122:17] the pastures in which the sheep will [122:18] graze and develop and grow. They [122:20] determine whether they're appropriately [122:22] nourished. They determine whether [122:23] they're protected from harm. [122:25] The environment is important, but it [122:27] doesn't design the sheep. No shepherd is [122:30] going to turn a sheep into a dog. Ain't [122:32] going to happen, right? [122:33] And yet that is what we see parents [122:34] trying to do all the time, and [122:36] especially parents of children with [122:38] disabilities. [122:40] So, step back and view yourself as the [122:42] shepherd to this disabled youngster, and [122:44] you get to design the pasture, and [122:46] that's very important, but you don't [122:48] engineer the sheep. [122:49] Now, that comes with it a profoundly [122:52] freeing view of parenting. [122:54] Because what it means is, although it's [122:56] important to be a shepherd, [122:59] recognizing that this is a unique [123:00] individual before you allows you to [123:02] enjoy the show, right? So, open a bottle [123:06] of chardonnay, kick off your slippers, [123:08] sit back, and watch what takes place, [123:10] right? [123:11] Because you don't get to determine this, [123:13] right? So, enjoy it. It doesn't last all [123:15] that long anyway. They're gone before [123:17] you know it, right? [123:18] But if you think that what you did in [123:20] your house is going to shape the life [123:21] course of this individual, you are sadly [123:23] mistaken, right? [123:25] This is a unique individual. Let them [123:27] grow, let them prosper. Please, design [123:29] appropriate environments around them. [123:31] But you don't get to design them. [123:33] As Judith Rich said in 1996 in the first [123:35] book on this subject written for lay [123:37] people, [123:38] the book is called The Nurture [123:39] Assumption. [123:41] As she said, you had more to do with [123:43] your child's life by where you chose to [123:45] live than by anything you will ever do [123:47] inside that home. Short of abuse, [123:50] neglect, or malnutrition, [123:52] the rest of it is just trivial [123:54] variation. [123:56] It's where you live. Why? Because [123:58] out-of-home influences are more powerful [124:01] in shaping the life course of your child [124:04] than in-home influences are. [124:06] And those out-of-home influences are [124:08] peer groups, other adults, [124:11] neighborhoods, resources, schools, and [124:15] the larger community that you made [124:17] available to this child. That is how you [124:19] shape your child's life course. [124:21] The second biggest influence is also out [124:23] of your hands, and that's genetics. And [124:25] you don't get to determine that. [124:28] But if you think parenting is so [124:29] influential, let me give you two [124:31] findings that have been replicated many [124:33] times. When we follow up twins, we are [124:35] able to calculate how much of their [124:37] behavior is due to parenting within [124:39] family environment. And here's what we [124:41] find. [124:42] The peak years of parental influence are [124:44] below seven. [124:46] From seven on to 12, it drops [124:47] dramatically. [124:49] After 15, it's 6%. [124:51] 6% of the variation in a teenager's [124:53] behavior is how their parents raised [124:55] them. That's it. And after age 21, it's [124:57] zero. [124:59] There is no influence of parenting on [125:01] any psychological trait after the age of [125:03] 21. Now, do not mistake what I'm saying. [125:06] The knowledge your child possesses, [125:09] what they know, is clearly a function of [125:12] exposure in the environment. [125:14] But their traits, their abilities, their [125:16] makeup, their personality is not. [125:19] So, the idea that somehow we design [125:21] these kids and we can get rid of ADHD [125:24] needs to be abandoned. [125:25] The other research finding is the [125:27] following, and it has been found in [125:28] every single study. There is no [125:30] correlation between any trait of an [125:32] adopted child and the people who raised [125:34] them. [125:34] None. [125:36] If you think parenting is so powerful, [125:38] prove it. [125:39] Otherwise, step back, accept your role [125:42] as a shepherd, do it well, and enjoy the [125:45] show. [125:47] It's going to be a unique set of [125:48] fireworks. I guarantee you that. [125:51] But now, not only do you not get the [125:54] credit, you also don't have to take the [125:56] blame. You didn't cause this ADHD or [125:58] whatever other disability your child [126:00] has. [126:02] Your child, because of the executive [126:03] deficit, is going to need to be made [126:05] more accountable to others. We've [126:06] already talked about a lot of this, but [126:08] let's just go back over it in more [126:09] specifics. First, you need to be much [126:12] more consistent with your rules and [126:13] consequences in raising this child than [126:15] normal parents need to be. [126:18] And that's not because you're going to [126:19] engineer the ADHD out of the child. It's [126:21] because you're going to make this child [126:23] less disabled from their ADHD by doing [126:25] that. ADHD is not information deficit [126:28] disorder, so kindly shut up. [126:31] Act, don't yak. [126:33] The more you blather, the more you [126:34] natter, the more you nag, the less [126:36] influence you have. [126:38] So, stop thinking that one more sentence [126:41] will be enough to tip the scales in [126:42] favor of obedience. It isn't, right? [126:46] If I can just say it one more time, I [126:48] know he'll listen. So, on the 20th time, [126:51] there you are, fingers crossed behind [126:52] your back. [126:53] Okay. [126:54] So, say it once, then back it up. What [126:57] these kids listen to more than anything [126:59] are the immediate consequences, not the [127:00] nattering, not the nagging, not the [127:02] moral essays and why you should clean up [127:04] your room to avoid meningitis. [127:09] Now, with ADHD children, you've got to [127:11] get their attention. One of the easiest [127:12] ways to do it, and also in an [127:14] affectionate way, is to touch them. [127:16] So, I want you to put your hand on their [127:17] arm, on their hand, or around their [127:19] shoulder. [127:21] When you talk to them, I want you to [127:22] look in their eye, and with that Clint [127:24] Eastwood look, [127:26] I want you to keep it short and sweet. [127:28] What do you want done? [127:30] What are you trying to say? Or, is this [127:32] positive feedback? Is this approval? Is [127:34] this recognition? Is this praise? [127:36] But, touch, then talk. Keep it short, [127:39] keep it sweet, get to the point, and [127:42] then back it up. [127:44] All right, if you're a parent with an [127:45] ADHD child, you better be setting a [127:46] timer to go off every few minutes and [127:48] check on where that child is. This is to [127:50] avoid accidental injury. It is also to [127:53] catch problems before they occur in [127:55] order to be a proactive parent. [127:58] And I'll show you what we call the [127:59] transition plan in a moment. I want you [128:01] to increase the frequency of [128:02] consequences for this child. Your child [128:04] needs much more external consequences [128:07] than other people. So, there's no need [128:09] to apologize for it. You're not going to [128:10] turn them into some little materialistic [128:12] kid, cuz he already is, anyway. [128:17] Okay. [128:21] Okay, here's one. He's got a short [128:22] attention span. Duh. Break the work into [128:25] small pieces. [128:27] Stop trying to torture his attention [128:29] span to become longer than it possibly [128:32] could ever be. [128:33] So, remember the 30% rule. Reduce the [128:35] age by 30%. That's his attention span. I [128:38] have to cut the work into that short a [128:40] period. So, instead of 30 problems all [128:42] at once, you get five. [128:45] Then you do them, bring them up to me. I [128:47] will take a pair of scissors and snip [128:48] off the next five math problems and give [128:50] them back to you. This is how you're [128:51] going to take exams. This is how you're [128:53] going to do your work. Small chunks, [128:55] frequent breaks. [128:57] Not one chunk all at once. [129:00] By the way, that is better than giving [129:01] extra time on an exam even to a college [129:03] student. Extra time on an exam to [129:06] someone with no sense of time is a dumb [129:08] idea. [129:10] You stole that from the learning [129:11] disabilities because you didn't know [129:12] what the heck else to ask for. So, I [129:14] guess we'll just ask for extra time. [129:16] Well, extra time to somebody with this [129:17] disorder is the definition of hell. [129:20] You want to know why? Because if you [129:22] have no sense of time, I want you to [129:23] remember back to when you were five and [129:25] it was the week before Christmas. What [129:26] did that feel like, huh? [129:28] Like molasses. It's slow moving. Well, [129:31] that's what it feels like to somebody [129:33] with ADHD, and you just gave them an [129:35] extra hour. Oh, great. [129:40] They're up. They're out. They're out the [129:41] door before you even know it. I love [129:43] this extra time recommendation cuz it's [129:45] so stupid, right? [129:48] What you should be doing is called time [129:50] off the clock. [129:52] You get a stopwatch. [129:54] On that stopwatch is going to be the [129:55] length of time everybody else gets. [129:58] Start the watch, and anytime you like, [130:00] you can stop it. Stand up, stretch, take [130:03] a break, ask me a question, come back, [130:05] start the watch. You will only get the [130:07] same hour as everybody else, but you get [130:09] to break it up as often as you like. [130:12] Will this take extra time? Of course, [130:14] but that is merely a byproduct of the [130:16] strategy. [130:18] Whereas telling somebody they have extra [130:20] time is not a strategy. [130:22] This is being done throughout the entire [130:24] state of Indiana by the Educational [130:25] Testing Service to prove that it is a [130:27] more compelling accommodation for taking [130:29] multiple choice time tests than is the [130:32] old extra time, which we already know is [130:34] going to fail anyway. [130:36] Break the work into pieces. [130:38] More frequent breaks, the work will get [130:40] done. You are going to have to use [130:42] external timers. We've already talked [130:43] about that. Now, we want you to become [130:45] proactive, not just in monitoring where [130:47] your kids are, [130:48] but also in transitioning across [130:51] activities. [130:53] So, that when you are making a major [130:54] change in what your family is doing with [130:56] this child, I want you to stop. [131:00] So, everything stops. Okay, hold your [131:02] horses, wait a second. It's homework [131:04] time. So, turn off the TV, [131:07] stop the action, and then I want you to [131:09] review two or three rules this child is [131:11] to follow in the next activity. Then I [131:13] want you to set up what is the [131:14] incentive? What's in it for him? What [131:16] are you offering? Points? [131:19] Tokens? Privileges? Extra time on [131:21] Nintendo or Gameboy or Wii or whatever? [131:24] What are you offering? Right? [131:26] Next, what's the punishment? What's he [131:27] going to lose? Make it clear. You're [131:29] going to lose that privilege, you're [131:30] going to lose those points, you're going [131:32] to lose that time on that computer, or [131:34] you're going to time out. Make it [131:36] obvious. [131:37] Get the rules up front along with the [131:39] consequences. Okay. Now, I want you to [131:41] distribute the consequences throughout [131:43] the task. You don't wait until it's [131:45] over. There should be rewards every so [131:47] often during the task, or they'll never [131:49] finish. [131:50] Then I want you to review with them. [131:52] What do you think? How did you do? How [131:53] could we do this better? Get their [131:55] opinion, invite them to self-evaluate [131:57] the activity. [131:59] If you will do that, you will cut your [132:00] problems by 50%. What do most parents [132:03] and teachers do? They do reactive [132:04] parenting. You go about minding your own [132:06] business, doing your laundry, fixing [132:08] dinner, until the problem occurs. [132:10] And now you are a problem-oriented [132:12] person. All you're doing is reactive [132:14] firefighting, we call it. [132:16] Had you just set your plan up front, [132:19] whether it's before you go into a store [132:21] or a restaurant or you start homework or [132:23] we go to recess or we have friends visit [132:26] or we go to grandma's house, every one [132:28] of those is a major transition. You need [132:30] to stop and do transition planning. [132:33] Now, what are you going to do when your [132:34] child is not with you? [132:36] You're going to get a behavior [132:37] monitoring card like the kind we use for [132:39] school, but this can be used anywhere, [132:41] anytime. It can be used for Cub Scouts, [132:43] Little League, soccer, hockey, going to [132:45] a friend's house, spending the afternoon [132:47] or evening or weekend with grandparents, [132:49] having a babysitter. Any place this kid [132:51] is going to be and you're not there, you [132:54] can monitor it with a monitoring card. [132:56] In the case of school, you're going to [132:58] use these rules and there's enough room [133:00] for all of his teachers and classes to [133:01] evaluate him using the rating at the top [133:03] of the card. One through five. [133:06] When this card comes home from school, [133:08] every teacher will have rated this child [133:10] at the end of every class, will have [133:11] initialed it to ensure against forgeries [133:13] because they will forge this card. [133:18] So, let's anticipate that. [133:20] All right, and then the parents are [133:21] going to review the card and the points [133:23] are in parentheses. That's how many [133:24] points you earn and then in the case of [133:25] fours and fives, which are lousy [133:26] ratings, that's how many points you [133:28] lose. [133:29] You are then going to add up the points, [133:30] subtract the negatives, that's what you [133:32] got to spend in your home on your little [133:35] token system, on your reward chart. But [133:37] you could do this for anything. It could [133:39] be for bus rides, it could be for [133:41] lunchroom, it can be for recess, it can [133:42] be for scouts. I don't care. [133:45] If he is away from you and there's [133:46] another adult there, that other adult [133:48] can be evaluating your child frequently. [133:50] Whether it's every 15 minutes, whether [133:52] it's at the end of every 45-minute class [133:54] period as it is in school, doesn't [133:55] matter. Frequent evaluation comes back [133:58] to you, you deliver the full [134:00] consequences based on that card. [134:03] And here again, you can start to cut [134:04] down problems by increasing [134:06] accountability even in places where you [134:08] can't. [134:16] All right, we've talked about the [134:17] behavioral adjustments. We've talked [134:18] about how to make these changes at the [134:20] point of performance, but let's also [134:22] face it, by themselves they're not [134:24] enough. [134:25] Only a third of ADHD children respond [134:28] enough to those changes to not need [134:31] medication. And even many of those would [134:33] still benefit from their medication. [134:36] But 2/3, and in my experience it's as [134:38] many as 80% are going to have to go on [134:41] medication at some point in life. Maybe [134:44] it's not this month. Maybe it'll be in 6 [134:46] months. Maybe it's a year. Just depends [134:48] on how compassionate and cooperative the [134:50] caregivers happen to be. And of course [134:52] how severe the ADHD happens to be as [134:54] well. But at some point these [134:56] medications will be needed for most [134:58] children. So I want parents to know them [135:01] and to know about them. Now if you're [135:02] looking for a very good book, the single [135:04] best book for parents on psychiatric [135:05] drugs is by Dr. Timothy Wilens. [135:08] Straight Talk About Psychiatric [135:10] Medication for Children. [135:12] You can get it at the ADD Warehouse. You [135:14] can get it through Guilford Publications [135:15] at guilford.com. Wilens, w i l e n s. It [135:20] is a parent's book on [135:21] psychopharmacology. [135:24] Straight Talk About Psychiatric [135:26] Medication for Children. [135:28] So quickly, let's go over what's out [135:31] there. [135:31] Right. First of all, parents need to [135:33] know we have stimulants. There are only [135:35] two now. [135:36] We have had them since 1936 for the [135:39] amphetamines and 1957 for [135:41] methylphenidate. They've been around a [135:42] long time, which means we know a lot [135:45] about them. We know how safe and [135:47] effective they are. These are the best [135:49] study drugs used in pediatrics and [135:51] psychiatry. So parents need to [135:53] understand that. We got a lot of [135:55] information out there on the safety and [135:57] effectiveness of these agents. [135:59] But there still is only two stimulants. [136:02] The news in the last seven or eight [136:04] years has been in the delivery systems. [136:07] Because the problem with the immediate [136:08] release medications is they only lasted [136:10] 3 or 4 hours. So, they had to be given [136:12] two to three times a day. So, you had to [136:14] take them at school and that created all [136:15] kinds of problems. [136:17] So, companies went back and [136:18] re-engineered delivery systems to try to [136:21] keep the drugs in the body for longer [136:22] periods of time on a single dose. And [136:25] they came up with four ingenious [136:27] delivery systems called the five P's [136:29] which I will tell you about in just a [136:30] moment. [136:32] Let's also understand that last year was [136:34] published the biggest study ever done of [136:36] stimulant safety for preschool children [136:39] with ADHD and they showed that the drugs [136:41] are effective and are safe down to age [136:43] two. So, the fact that we are seeing [136:46] some of these drugs instituted younger [136:48] in life than previously is nothing to [136:50] worry about. It looks okay. The [136:53] preschoolers don't respond quite as [136:55] well. But apart from that, there are no [136:58] new side effects and there's certainly [136:59] nothing life-threatening about using [137:01] them. [137:02] The other new agent we have out there is [137:04] atomoxetine. This is Strattera, approved [137:06] in 2003 in the US and about a year later [137:09] here in Canada. Strattera is not a [137:11] stimulant. It is not an abusable drug. [137:14] Uh and it is nearly as effective, though [137:17] not quite as effective as the [137:19] stimulants. But for some children with [137:21] particular [137:22] uh ADHD comorbidities like tics, [137:24] anxiety, Tourette's, OCD, insomnia and [137:28] so forth, atomoxetine can be a good [137:30] alternative drug because it doesn't [137:32] worsen those comorbid conditions. [137:35] Now, you should also be aware that this [137:37] August, the US will have a new drug on [137:39] the market for ADHD. It will be [137:41] guanfacine XR. Guanfacine XR will be [137:44] called Intuniv. This is not a stimulant. [137:48] This is an antihypertensive drug. It has [137:50] been used for years with ADHD children, [137:52] especially if they have Tourette [137:54] syndrome or bipolar disorder or very [137:56] explosive behavior because the [137:58] antihypertensive drug appears to help [138:01] lower emotional impulsive behavior in [138:04] the individual. [138:06] But Shire has now been able to [138:07] manufacture a long-acting version of [138:10] guanfacine, previously called Tenex, and [138:13] it will be marketed under the guanfacine [138:15] label. I expect that you guys will [138:17] probably see it a year or two after we [138:19] get it. [138:20] Now, let's go back to the five P's. [138:22] These are the new delivery systems. The [138:24] first P is the pellet system, excuse me, [138:27] the pill system. My apologies. [138:29] The pills are the original forms of the [138:31] drug. Ritalin and Dexedrine are in their [138:33] original pill form. It lasts about 3 to [138:35] 5 hours. So, what's new? They put them [138:38] in a pump. [138:39] This is Concerta. Concerta is a [138:41] miniature hydraulic pump. [138:44] So, that when you swallow this, there is [138:46] powdered Ritalin on the outside of this [138:49] little capsule. And it goes to work [138:51] immediately. And then on one end of this [138:53] capsule, barely visible to you, is a [138:55] laser-hilt drilled hole at the end of [138:57] the capsule. Inside the capsule is a [139:00] methylphenidate sludge in two doses. A [139:02] light dose at the beginning, double the [139:05] dose in the afternoon. [139:06] When you swallow this, water is going to [139:08] come in to this upper chamber at a [139:10] continuous rate, and it's going to push [139:11] down on this, and like a tube of [139:12] toothpaste, it's going to squeeze liquid [139:14] Ritalin out for about 10 to 12 hours. [139:17] That is really neat. And then the pill [139:20] is excreted um in the the child's uh [139:23] excrement. So, you've got a drug that [139:25] can last around 10 hours. Some kids it's [139:27] only eight, others get as much as 12, [139:29] but about eight to 10 is about right. [139:31] That is a really neat system. [139:34] The next system is the time-release [139:36] pellet system. So, we've got the pill, [139:39] the pump, and now the pellet. The [139:41] time-release pellets are what Adderall [139:43] XR involves, Focalin uh [139:47] LA I think or XR, Ritalin LA, they're [139:49] all time-release pellets. [139:51] And guanfacine XR is going to be the [139:53] same way. So, you have different pellets [139:55] of medication, in this case amphetamine. [139:57] They're coated with different time [139:59] release coatings. Some dissolve right [140:00] away, some in an hour, two, three, four, [140:03] up to eight to 10 hours. [140:05] So, is there any difference between the [140:07] pellet system and the pump? Not really [140:10] over the day. [140:11] But, on the time of day, there is. [140:14] The pellet system is better if the [140:16] problems are greatest in the morning. [140:17] The pump system is greater or better if [140:19] the problems are toward the afternoon or [140:21] late in the day. But, other than that, [140:23] across the day, they cover about 8 to 10 [140:26] hours. [140:27] Excuse me, I want to get rid of that. [140:30] Okay, hold on. [140:32] The next P. I don't know if you have [140:33] this up here in Canada. [140:35] This is the patch. Okay, this is [140:37] Daytrana. [140:38] This is methylphenidate in a skin patch. [140:40] Wear it on the buttocks, wear it on your [140:42] shoulder, on your hip. Wear it all day [140:44] long. That's it. It's absorbed through [140:45] the skin. No taking pills. [140:48] This is a very hard drug to abuse [140:49] because you can't snort the patch, [140:52] right? [140:55] But, there's a problem. About 15 to 18% [140:57] of patients develop a skin rash to this [140:59] and can't tolerate it and it's due to [141:01] the drug. But, 80 84% of the people can [141:04] tolerate the skin patch. So, it's pretty [141:06] good as an alternative. Oh, by the way, [141:09] I I meant to mention under the pellet [141:10] system, one of its advantages is if a [141:12] child can't swallow a pill and you don't [141:14] have the patch available, you can open [141:16] the capsule and sprinkle the pellets on [141:18] food. Like on yogurt or applesauce. [141:21] Doesn't change the delivery at all. [141:24] Um so, that's another advantage of that. [141:26] Finally, last August, we have the first [141:28] drug of its kind ever produced. This is [141:30] Vyvanse. It's a form of amphetamine. [141:33] It's called a pro-drug. Hence, the last [141:35] P. What is a pro-drug? A pro-drug is [141:38] where you take a chemical, in this case, [141:40] amphetamine, [141:41] and you lock it up. Okay, this is the [141:44] amphetamine right here, and you lock it [141:46] up with another chemical, so it can't [141:48] work. [141:50] Now, this drug will only work after you [141:53] split off, in this case, the lysine. [141:56] You swallow Vyvanse, there's a chemical [141:59] in your body that will split off the [142:00] lysine, and now the amphetamine can go [142:03] to work. This is the first non-abusable [142:06] amphetamine ever invented because it [142:08] only works in the stomach and after it [142:10] crosses through the intestine into the [142:12] bloodstream. And that's where the [142:15] chemical is, the enzyme that splits off [142:18] the lysine. [142:19] And now it goes to work. So, we have a [142:21] non-abusable amphetamine on the market [142:23] in the US. I don't know if you have [142:25] Vyvanse yet. [142:26] It's probably coming this year, I [142:27] believe. Okay. [142:30] So, just be aware that it's down there. [142:32] Vyvanse is a little better than Adderall [142:34] XR, which is the other drug made by the [142:36] same company, and it's replacing it in [142:38] the US because Vyvanse lasts 2 hours [142:41] longer [142:42] than the other drugs do. This is about a [142:45] 12-hour drug. [142:48] It also has a softer onset and a softer [142:50] offset, unlike Adderall. [142:53] So, it's a pretty good drug. [142:54] I want parents to understand there are [142:56] misconceptions afoot about the [142:58] stimulants. They are not addictive as [143:01] prescribed unless you inject or inhale [143:02] them. They do not produce aggression and [143:04] they didn't cause Columbine. They are, [143:07] in fact, able to reduce aggressive and [143:09] antisocial behavior. They do not cause [143:11] seizures, you'd have to swallow the [143:12] whole bottle. [143:14] So, even children with seizure disorders [143:16] can take these drugs safely. They do not [143:18] cause tics or Tourette's unless you [143:21] already are prone to tics or Tourette's, [143:23] and then they may bring them out and [143:25] make them worse. Even then, [143:27] only in about 30% of the cases. The [143:29] remaining cases do not experience a [143:31] worsening [143:32] of their tics, and so children with ADHD [143:34] and tics can take these drugs safely as [143:37] long as they're not one of the 30% that [143:38] makes it worse. And by the way, the [143:40] worsening is temporary. Stop the drug, [143:42] the tics will go back to their baseline [143:43] within a week. [143:45] Are we overdosing ADHD children in North [143:47] America? Absolutely not. [143:50] If you look at the prevalence of the [143:51] disorder, it's 7 and 1/2%. If you look [143:54] at how many children are taking [143:55] medication, it's between 4 and 5%. [143:58] Which means you are missing a third of [144:00] all children. And by the way, 90% of all [144:04] adults with ADHD are not treated. [144:07] So, are we using more medication than [144:09] ever before? Yes. Is it scandalous? No. [144:12] What's our problem? We still have people [144:14] who don't have access to care and who [144:16] aren't being treated for their disorder. [144:18] And that's the real problem as our [144:19] Surgeon General pointed out, not [144:21] over-treatment in the United States or [144:24] up here. [144:27] Is there a risk of later substance abuse [144:29] from the stimulants? Your own CBC ran a [144:31] program on Marketplace the Marketplace? [144:34] That what it's called? Right? The one [144:36] with that little blonde hottie that used [144:37] to date your Member of Parliament? [144:40] I just want to make sure I got the right [144:41] program. That's all. [144:43] Everybody knows when I say that. Oh, [144:45] her. Yeah, we know. Okay. [144:47] I have a bone to pick with that because [144:49] they were in fact deceitful [144:53] in their creation of that program, [144:55] especially with our medical school. [144:58] But nevertheless, they ran a program [144:59] claiming that stimulants can predispose [145:01] children to cocaine abuse, nicotine, and [145:04] other drugs of abuse later in life if [145:06] your children took them. This is based [145:07] upon a single study done by Nadine [145:09] Lambert in San Francisco. [145:12] Nadine study has many, many flaws in it, [145:14] not the least of which is she never [145:15] controlled for conduct disorder, which [145:17] is the biggest predictor of drug abuse [145:18] among ADHD children. And when you [145:20] control for that, there is no link [145:22] between being treated with a stimulant [145:24] and abusing any drug. How do I know [145:26] that? Because 17, you can correct this [145:29] slide, 17 studies, including my own, [145:32] have now shown no relationship between [145:35] length of time you take a stimulant [145:36] throughout childhood and risk of any [145:39] abuse in adulthood. So, there's your box [145:41] score. 17 to one. What did the CBC focus [145:44] on? The one. [145:45] Why? Because we all know now that [145:48] televised journalism is a form of [145:50] entertainment, [145:52] not a form of information. That they go [145:55] after the scandal, [145:57] the underbelly, the sensational side, [146:00] and they ignore anything that does not [146:02] fit that preconceived idea. And that's [146:04] exactly what the CBC did, which was, I [146:06] think, a travesty of journalism. [146:10] Do they improve academic achievement? [146:12] No, not at the start. But we now have [146:14] several studies, including one published [146:16] a week ago, that show that if you stay [146:18] on your medication at least two years or [146:20] more, we do start to see an uptick in [146:22] academic achievement skills. [146:24] But prior to that time, what the drugs [146:26] are doing is improving your [146:27] productivity, the amount of work you do. [146:30] But there's no knowledge in a pill. [146:33] So, why would you know your [146:34] multiplication tables when you take your [146:35] Concerta when you didn't know them the [146:37] day before, right? [146:39] But what the drugs do is to make you [146:42] available for learning. And if you stay [146:44] available for learning over a long [146:46] enough period of time, you do learn [146:47] more. [146:48] But not in the short run. [146:50] And then I mentioned Strattera. I'm not [146:52] going to go over that cuz I've already [146:53] mentioned it, but it is the [146:55] non-stimulant on the market right now, [146:56] and as I said, we will have another one [146:58] later on. It's a very good drug, [147:00] especially for kids who have anxiety or [147:03] tics or OCD or insomnia [147:06] or other sleep problems. [147:08] Okay, the next thing I want parents to [147:10] understand is to avoid treatments that [147:13] we know don't work or that have a very [147:16] low probability of succeeding. [147:19] By the way, if these don't correspond to [147:20] your manual exactly, I changed a few of [147:23] them yesterday, okay? I try to keep my [147:26] slides as up-to-date as possible or when [147:28] I go through them and I don't like the [147:29] teaching the the flow, I may change them [147:31] a little bit. So, if you're not seeing [147:32] exactly what I have, my apologies, but [147:35] you've got 99% of what I've been talking [147:37] about. [147:39] These are the things to avoid, all [147:40] right? Why? Because either they're so [147:42] silly, we're never going to look at [147:43] them, all right? [147:45] Or they've already been looked at and [147:46] they don't work, right? [147:48] Taking something out of the diet [147:51] benefits about one out of every 20 ADHD [147:53] children. We're talking here about [147:54] colorings, flavorings, and [147:56] preservatives. [147:58] Do some ADHD children react adversely to [148:00] these? Yes. [148:02] Do most? No. [148:04] It's mainly children five and younger [148:07] and it's about one in 20. [148:10] So, do we recommend elimination diets as [148:12] a blanket panacea treatment for ADHD as [148:15] was done by Feingold and others? No. [148:18] Might it benefit the occasional rare [148:20] child? Yes. [148:22] Next, there is nothing you can put in [148:24] the diet that treats this disorder. [148:26] So, whether it's antioxidants, whether [148:28] it's the fish oils, whether it's mega [148:30] vitamins, we have yet to find anything [148:33] that benefits ADHD. The fish oil study, [148:36] the best one was published just a month [148:38] ago by the Swedish research team in [148:40] Gothenburg. [148:42] Uh best trial I've ever seen and they [148:43] reported very sobering negative results. [148:46] Only 25% of the kids responded. It was [148:48] mainly the inattentive SCT kids. The [148:51] degree of response was very slight. [148:53] So, even they recommended against it. [148:55] Any positive reports you've heard were [148:58] not from well-controlled studies. [149:01] Now, I'll get to my questions in just a [149:02] moment. Yeah. [149:04] Sure. [149:05] In emergency, we need a Daryl McMichael [149:10] to come to the phone immediately. [149:12] Thanks, Heidi. I'm sorry about that. [149:14] Thank you. Sorry. [149:15] Yeah. [149:18] Next, fastest growing treatment in the [149:20] US school system right now for ADHD is [149:22] sensory integration training. This is a [149:24] special set of exercises done by some [149:26] occupational therapists who have gotten [149:27] additional training in the SI techniques [149:30] and in assessing for sensory integration [149:32] problems, this has been resoundingly [149:35] disproved. [149:36] So, this is an area that has been [149:38] studied, but you'd never know it by the [149:39] number of people being exposed to this [149:41] treatment. It is proven to be of no [149:43] benefit for LDs or ADHD. Even their own [149:46] journal published a meta-analysis that [149:48] showed that, and yet we go on seeing [149:51] sensory integration being offered as a [149:53] special set of exercises to treat ADHD. [149:57] Why would massaging the head do anything [149:59] for ADHD? Yet, chiropractors do engage [150:02] in what is called skull massage or [150:05] neurologic organization training, [150:07] claiming that they can successfully [150:09] treat ADHD through skull massage. It's a [150:12] silly idea. We won't go there. [150:14] Play therapy has been tested. It does [150:16] not work for ADHD because ADHD does not [150:18] arise from environmental stress. [150:21] So, why would helping children cope with [150:23] stress solve this problem? [150:25] That does not mean it may not benefit [150:27] anxious children, PTSD children, or [150:28] children with depression, but it doesn't [150:31] benefit ADHD children for their ADHD. [150:35] Self-control training I mentioned [150:36] earlier, this is talking to yourself. [150:39] So, teaching children to talk out loud [150:41] as they perform a task, we had great [150:43] hopes for this, and it failed. [150:45] But, the diamond in that dung heap is [150:47] that we found that it was age-related. [150:49] The younger you are, the less likely it [150:51] works. But, by late adolescence to [150:53] adulthood, it does work, [150:55] but only if you're on medication. [150:58] It is a supplement to medication, not a [151:01] form or alternative to medication. There [151:03] are several books on the market now that [151:05] were developed by these researchers. One [151:06] is Steve Saffron at Harvard Med School. [151:09] He now has a cognitive therapy manual [151:11] for adult ADHD, and the other is by [151:13] Russell Ramsey at Penn State or [151:15] University of Pennsylvania. You could [151:17] find both of these at [151:18] amazon.addwarehouse.com if you're into [151:19] adult ADHD treatment. [151:24] Social skills training should not be [151:26] done for the average ADHD child unless [151:28] it's being done at school or with the [151:30] peer group with whom he is having [151:31] trouble. [151:32] And then it should be mostly practice, [151:35] queuing, and rewarding the use of the [151:38] skill. [151:39] And a lot less time spent in training [151:42] the skill. [151:43] What's the proportion? 80/20. [151:45] 80% altering the point of performance, [151:47] 20% training in the skill. [151:50] And if you follow that balance and you [151:51] do it out there where it matters, it [151:53] might have a chance. If you do it in the [151:55] clinic with the kids he'll never see [151:56] again the rest of his life, it doesn't [151:57] work. [152:00] Next to the last idea for you, right? [152:03] 25 to 35% of the parents of ADHD [152:05] children are ADHD themselves. [152:08] It used to be people didn't care. They [152:10] didn't ask. They didn't want to know or [152:12] they didn't think it mattered. Now we [152:14] know it matters. [152:15] First of all, it matters that your own [152:17] ADHD needs to get treated because we've [152:19] studied now the impact of ADHD on [152:22] parents. Whether they have ADHD children [152:24] or not. We now have a series of studies, [152:27] particularly the work of Charlotte [152:28] Johnston at University of British [152:29] Columbia and Andrea Chronis at [152:31] University of Maryland, who have now [152:33] studied parents who have this disorder [152:35] and what it does to their parenting. And [152:37] you can see the obvious things here. [152:39] Greater impulsiveness, higher rates of [152:40] expressed emotion, greater rates of [152:42] disciplining, [152:44] lower rates of parental monitoring of [152:47] children. [152:49] All of which increases the risk for [152:50] oppositional disorder in the child. [152:53] So, the parent's ADHD needs to be [152:55] detected and managed, not just the [152:57] child's ADHD. And also more recently, it [153:00] is the best predictor of who fails in [153:03] behavioral parent training if the parent [153:05] themselves has the same disorder. [153:07] My last admonition to you is one that [153:09] Leo Buscaglia wrote about 30 years ago [153:12] in his book for families of and [153:14] autistic children. [153:16] In this book, Buscaglia said one of the [153:17] most important things a family of a [153:19] disabled youngster can do is to practice [153:22] forgiveness. [153:24] And he meant by this four things. [153:26] You better get good at forgiving [153:28] yourself for your mistakes. You will [153:30] make them. We all make them. Even [153:32] raising normal children, you will make [153:34] more of them because ADHD children know [153:36] just how to push your buttons to get you [153:39] to do things you regret. [153:42] So, you better get good at forgiving [153:44] yourself those mistakes. And if Judith [153:45] Harris is correct, you don't matter [153:47] anyway. [153:50] You're not as important as you thought [153:51] you were. [153:52] So, relax a little bit. It's okay. You [153:55] know what really matters, as Pascale you [153:56] said, [153:57] do you try to get it right the next [153:58] time? [153:59] It's not did you make the mistake. It's [154:01] what are you going to do about it [154:02] tomorrow to make sure that it doesn't [154:04] happen again. That's a very important [154:06] idea. [154:08] One of the things that I think um [154:10] that will be very helpful in helping you [154:12] to do this uh is to step back to that [154:15] principle about being a shepherd. [154:18] You're not an engineer. [154:20] So, it matters what you do, but it [154:22] doesn't matter that much what you do. [154:24] And I find it's better if you have the [154:25] shepherd's view because you start to [154:27] look at your children in a very [154:28] different light as things to be enjoyed [154:32] and celebrated and cherished for their [154:34] uniqueness [154:35] as opposed to being [154:37] mounds of clay that you can sculpt into [154:39] whatever you choose to do. You just [154:41] don't have that kind of power. [154:44] The second area of forgiveness is that [154:45] of your child. This is harder, okay? [154:48] This is harder because resentment can [154:50] build up. The mistakes are there. The [154:51] misbehaviors there. You are being given [154:54] misbehavior 24/7 [154:56] that you have to deal with. You have had [154:58] to step up to the plate and become your [155:00] child's frontal lobes, and it's not [155:03] easy. It is exhausting. [155:05] And there's a tendency among some [155:07] parents to allow a certain amount of [155:08] resentfulness to creep into this. A wish [155:11] that you had a different child, a better [155:12] child, a normal child. And boy, that is [155:15] just one step away from justifying child [155:18] abuse. [155:19] The idea that your child may be doing [155:20] this intentionally [155:22] is one of the sources of resentfulness. [155:25] So, you better get good at forgiving [155:27] these kids their mistakes. They make a [155:28] lot of them, all right? So, here's a [155:30] couple of suggestions that parents have [155:31] told me about that work for them, and I [155:33] love these ideas and I put them in my [155:34] parents book. Number one, [155:37] at the end of the day, [155:39] after dinner, when you're having your [155:41] coffee or your cognac or whatever, [155:44] I want you to take out a sheet of paper. [155:46] I want you to write down all the [155:47] problems you had with this kid today. [155:50] Write them all down, every one of them, [155:51] all right? Exorcise your demons. Get [155:55] them down on the paper. [155:57] Then I want you to go to the sink, take [155:58] a match, and light them. I want you to [155:59] burn them all up. There they go. [156:02] Gone. [156:03] You have now performed a ritual [156:04] exorcism. The demons are gone, the day [156:06] is over. Let it go, all right? [156:11] The second thing one of the parents [156:12] taught me that she found was so useful [156:15] is after your child has fallen asleep, [156:18] go upstairs, [156:20] sit on the floor in a yoga position, you [156:22] know, [156:24] and watch your child sleep. [156:28] Just breathe in and out and watch. There [156:30] is nothing more innocent than watching a [156:33] young child sleep. [156:36] And if that doesn't renew your batteries [156:38] and restore your balance to your view of [156:40] your child, I'm not sure what will. [156:43] Maybe a glass of wine while you're [156:44] watching the child fall asleep. [156:47] But whatever it takes to let these go [156:50] and to try to get better tomorrow, [156:53] that's what really matters, [156:55] not the mistakes you make. And the same [156:56] applies to your partner or your spouse. [156:58] Don't get all upset because they're not [157:00] doing it quite the way you want it done [157:02] or vice versa. [157:04] And then, of course, the last one is the [157:05] one you're all here for, I hope, as [157:07] well, [157:08] and that is to learn more about ADHD. [157:10] But in learning, you realize that the [157:12] public doesn't understand this disorder [157:13] the way we do. [157:15] That they are ignorant of this disorder [157:17] and its causes. So, you better get good [157:20] at forgiving other people who glare at [157:22] you in Walmart because your child is a [157:24] handful. [157:26] Who stare at you in the Outback [157:28] restaurant. [157:30] Who look at you as if this is your [157:32] fault. My sister-in-law has an ADHD son. [157:36] This is my nephew Dan. [157:38] One time she was in Target. And an older [157:41] woman came over to her and said, "Why [157:43] don't you control your child? You know, [157:45] this is all your fault. If young parents [157:47] like you would just take this bull by [157:48] the horns and discipline these kids [157:50] more, we wouldn't be having these [157:51] trouble." And she followed my [157:53] sister-in-law out the car out to the to [157:55] the car. At the car, stood there yelling [157:58] at her while she locked her door and she [158:00] was in tears over this. Now, that's an [158:02] extreme example, but don't tell me this [158:04] can't happen. [158:05] Most of you have had these looks thrown [158:08] at you about your child. And sometimes [158:11] it goes up a notch. [158:12] So, you better get a thick skin about [158:15] the public that doesn't understand this [158:17] disorder. Now, there's a cognitive [158:19] therapy technique that you can use. [158:21] While you're looking at these people, [158:23] you can be saying in your mind, "What's [158:25] it to you, pork face?" [158:29] But I don't want you to say it out loud, [158:32] right? [158:33] This is just cognitive therapy. You're [158:36] an idiot. You don't know what you're [158:38] talking about. If you had one of these [158:40] kids, walk a mile in my shoes. But just [158:43] shut up, drive on, get on with your [158:45] life. But you better get good at [158:46] forgiving the public they're [158:47] misunderstanding. Cuz boy, do they [158:49] misunderstand this disorder. [158:52] I'll hang around for a few questions, [158:54] but I hope you enjoyed the 30 things [158:56] families need to understand about ADHD. [159:00] Thank you. [159:22] Does the 30% rule apply to on [159:24] medication? No, because in 55 to 65% of [159:28] the cases of children, the medication [159:30] will normalize them. [159:32] So, that's that's over a half and in [159:34] some cases 2/3. [159:36] The 30% is gone. Only when the [159:39] medication is active. So, at the end of [159:41] the day, here it comes and by 8:00 at [159:45] night, you're back to 30% again. So, [159:47] just keep in mind that it can normalize [159:49] some children. In the remaining 30%, the [159:52] gap is closed, but not completely. There [159:55] is improvement, but not normalization. [159:58] Other things will have to be done [160:00] to help with that gap. And then there's [160:02] about 10 to 15% of the kids who don't [160:05] respond to any particular agent. [160:08] And in that case, you're just going to [160:09] have to deal with the full 30% and [160:11] accommodate it as best you can. So, good [160:13] question. [160:28] Well, I don't know that there's one best [160:30] way because let's face it, there are [160:31] some neighbors or some parents of other [160:33] friends who are going to respond to [160:35] anything. [160:36] And they don't want your kid around and [160:38] it's best that your child find another [160:40] set of friends or stay away from that [160:41] home. They don't need to be hearing that [160:43] stuff. But most parents are fairly [160:45] reasonable people and I think if you [160:47] went to them, if you downloaded a fact [160:49] sheet on ADHD from my website or the [160:51] CHADD website, uh and you just took it [160:54] to them, this sort of two to three-page [160:56] description, or you called them and [160:58] said, "You know, I've been meaning to [160:59] come by or have you over for a coffee or [161:01] as part of this little social coffee [161:03] clutch or whatever, you introduce this [161:05] information about your child, about [161:06] their diagnosis, about what it is, and [161:09] the various things that you you all are [161:10] trying to do to contend with it. I think [161:12] you you might find these people being [161:14] more compassionate than they ordinarily [161:16] would. They're probably laboring under a [161:17] lot of misimpressions that the public [161:19] has anyway. That this your child could [161:22] be better, this is your fault, it's a [161:23] result of parenting, and we sort of need [161:26] to disabuse them of those ideas. But I I [161:28] like the honesty is the best policy [161:30] approach to begin with. Now, obviously, [161:32] if in the middle of this conversation it [161:33] becomes very clear that these parents [161:35] don't care, don't understand, and don't [161:37] want to, then you you should not be [161:39] allowing your child to play at their [161:41] home or under their supervision. Um feel [161:44] free to invite their child over to your [161:45] house if they'll allow it, but uh I [161:48] still think informing the public. Uh [161:50] we've had some teenagers carry around a [161:52] card about ADHD in their wallet so that [161:55] they can show it to people who are not [161:56] familiar with ADHD, a coach or a [161:59] policeman that pulls them over for [162:00] speeding or you know, something like [162:02] that, but [162:04] uh very much like we got the idea from [162:05] the Tourette Syndrome Foundation, which [162:07] publishes small cards that are [162:09] information that allow Tourette's people [162:11] to share the information without [162:13] necessarily having to explain it all [162:14] themselves, but here's a sheet from a [162:17] reputable source like CHADD or my [162:19] website that that they can learn from. [162:21] The most you can do is to try to [162:22] persuade them, inform them, maybe change [162:24] their mind, and then the rest is [162:26] shopping for more reasonable friends and [162:28] parents of friends if you can. Now, some [162:30] people ask, "Well, what what my child [162:32] doesn't have an awful lot of friends. [162:34] What can I do to try to improve that?" [162:36] Make your house the best place to play [162:38] on the street. [162:41] It's bribery, but I don't care how you [162:42] do it. You need to have the best toys in [162:44] the yard, you will need to have the best [162:46] games in the house, you need to be [162:47] somebody who feeds all visitors. [162:50] So that when everybody and anybody shows [162:52] up, man, there's a fudge sickle in your [162:54] hand and an Oreo and a glass of milk, [162:56] and here's the Wii system and I mean you [162:59] are just going to create this place [163:01] where they love being there whether your [163:02] son is there or not, right? [163:05] Uh and hopefully some of these [163:07] friendships will stick or take or [163:09] they'll be a little more forgiving of [163:10] your child's immaturities because you're [163:12] such a great place to be. [163:15] Um however you can arrange this [163:16] environment. You can't make other [163:18] children like your child. [163:20] That is not possible to do. [163:23] You can only make them more likable or [163:26] make the environment in which your child [163:28] exists more likable and hopefully some [163:31] of that sticks. So approach it that way, [163:34] but you can't make another child want to [163:35] play with your child. It's just not [163:37] going to happen. Those children make [163:38] their own choices. [163:45] There are a number of treatments on the [163:47] market right now that are based on these [163:49] neuropsychological theories of ADHD as [163:51] an executive disorder, particularly that [163:54] involves working memory. Uh Torkel [163:56] Klingberg is the developer of Cogmed. [163:58] It's a He's a Swedish scientist. Uh [164:01] Cogmed is is working memory training. [164:03] It's practicing digit span forward and [164:05] backward and spatial memory forward and [164:07] backward for about 45 minutes a day with [164:09] your child. You do need to reward them [164:11] because it's gets boring to tears after [164:13] the first day or two. [164:14] Uh so you have to have a token system [164:16] and a reward program in place. Program [164:18] costs several thousand dollars. Now, I'd [164:20] have I have visited [164:22] Sweden and his lab. I've gone over their [164:24] data. And it does look like this [164:27] produces a temporary improvement in [164:29] working memory and that result in a [164:31] temporary decrease in ADHD symptoms. But [164:34] even Klingberg has shown that with three [164:37] months of training or up to six months [164:39] of training, the effect might last maybe [164:41] three months. [164:43] And then you have to start the [164:44] retraining again. So this is He likens [164:47] it I think very aptly to an athlete like [164:49] a weightlifter trying to train muscle [164:51] mass. [164:52] This isn't anything willful. You're just [164:54] trying to expand the capacity of the [164:56] brain for working memory. And just like [164:58] an athlete who exercises, I can build up [165:00] my biceps. But if I stop exercising for [165:02] a month, guess what's going to happen? [165:04] My bicep is going to atrophy now because [165:06] it's not being exercised as much. And [165:08] the same is true with these [165:09] neuropsychological training programs [165:11] that we have seen so far. [165:13] Now, [165:14] Klingberg gets royalties from the [165:16] company, and we would like to see his [165:18] research replicated by someone who does [165:20] not have a financial stake in the [165:22] success [165:23] of the company. So, it is being tested [165:25] at five universities in the US. I know [165:27] of at least one here in Canada as well. [165:30] When these studies are over, we're going [165:31] to have an idea about whether his [165:32] findings could be replicated. But even [165:35] if they are replicated, let's not forget [165:37] what he found. This is a temporary [165:39] exercising program that has to be [165:41] reinstituted several times a year to [165:44] sustain the gains. Now, let me tell you [165:46] something else. If it turns out that [165:48] this works, [165:50] why would you spend several thousand [165:51] dollars when you can buy a Nintendo DSS [165:55] and the Brain Age software, which does [165:57] both of these things as well as at least [165:59] six other frontal lobe executive [166:01] function tasks? It's just as much fun if [166:04] not more so. [166:05] It's 1/10 the cost. [166:08] So, I would direct you to Nintendo [166:10] before I would say send you to Cogmed. [166:12] And if you don't want to invest the [166:14] couple hundred bucks that DSS costs with [166:16] the software, [166:18] get Scientific American Mind. This is [166:21] the popular science magazine Scientific [166:23] American. They also publish one called [166:25] Scientific American Mind. The last issue [166:28] of Mind [166:29] was a review of all internet sites that [166:32] have executive function training [166:34] programs on them. Where you can go, some [166:36] of them are free, most of them [166:38] have a monthly fee that you can sign on [166:40] for. And there's the software, there's [166:42] the games, there's tracking your [166:44] successes and failures. All the things [166:46] that Nintendo and Cogmed are doing can [166:48] be done through these websites without [166:50] buying the equipment usually for like [166:51] nine or 10 bucks a month. Some are more, [166:53] some are less. Some are more [166:55] interesting, some are less interesting, [166:57] but there's a review of all of these [166:59] brain training websites in that magazine [167:03] and it's very good. [167:04] By the way, Nintendo comes out looking [167:06] really good because it's the only [167:07] portable system you can take anywhere [167:09] and practice anytime even if you're [167:10] waiting in a car for little league to [167:12] start, you know. So, [167:14] look around. Cogmed isn't out there, but [167:17] let's wait for the research to come out [167:18] before we know whether this is really [167:20] going to turn out to be a a coping tool [167:23] and that's all it is. It is not a cure, [167:25] not by any means. That was probably more [167:27] information than you ever wanted to [167:28] hear, right? [167:30] Okay. [167:46] All right, here is the relationship, [167:47] right? The relationship between ADHD and [167:49] bipolar is a one-way street. [167:52] ADHD children carry no elevated risk for [167:54] bipolar disorder over that of the [167:56] general population. No longitudinal [167:58] studies have found that to be the case, [167:59] my own included, not the Canadian [168:01] studies, not the New York studies, not [168:02] the Iowa, not the Swedish, not the [168:04] Australian. Risk is 2 to 4%, which is [168:06] the population rate. So, if a child [168:08] starts out ADHD, that's probably what [168:11] they're going to stay. Bipolar becomes a [168:13] very remote diagnosis. [168:16] However, [168:17] if there is bipolar disorder in the [168:19] family, the risk goes up eight times. [168:23] Now, [168:24] the real relationship is from bipolar to [168:27] ADHD. [168:29] If a child has bipolar disorder already [168:32] and it started in childhood, [168:35] the risk is 80 to 97% that they will [168:37] have ADHD along with it and that is why [168:40] the confusion. People saw that so many [168:42] bipolar children had ADHD, they made the [168:45] leap that the opposite had to be true, [168:48] that ADHD was a big risk for bipolar, [168:50] and it turned out to be no risk for [168:51] bipolar disorder, unless the family [168:54] history of bipolar illness is there. And [168:56] then the genetic risk for bipolar [168:58] disorder, obviously, are what mediate [169:00] that high risk. So, bipolar disorder, [169:03] only if it starts in childhood, carries [169:05] a very high risk for ADHD along with it, [169:08] and ADHD is usually the first disorder [169:10] to start. [169:12] If the bipolar starts in adolescence, [169:14] the risk is 40 to 45% that ADHD is with [169:16] it. If it starts in adulthood, which is [169:18] the more typical form of bipolar [169:20] disorder, the risk is only 20 to 25%. [169:22] So, notice it's the early onset bipolar [169:25] that brings the risk of ADHD with it, [169:27] not the other way around. [169:29] Now, if there's bipolar there, and it [169:31] started in childhood, it is one of the [169:32] worst psychiatric disorders a child can [169:34] have, barring infantile autism or [169:36] schizophrenia. Very difficult to manage. [169:39] It requires multiple medications to try [169:41] to deal with it. There is, obviously, an [169:43] increased risk of, uh, not just [169:45] destructiveness, but violent behavior, [169:47] particularly in males. [169:49] Uh, there is periodic hospitalization [169:51] for safety, as well as for, uh, [169:53] re-engineering [169:54] the psychopharmacology, that is, testing [169:56] the drugs. Many of the drugs used with [169:58] bipolar disorder have far more serious [170:00] side effects than the ADHD drugs do, and [170:03] so children are often hospitalized [170:04] partly to monitor the side effects as [170:07] they're titrating them. The bipolar [170:09] child has a massive increase in risk for [170:11] suicide and drug abuse as they enter [170:14] adolescence. [170:15] Uh, so this is not a fun disorder. But [170:18] it's 2 to 3% roughly of children have [170:21] the bipolar disorder, and it is severe, [170:23] and it is usually lifelong, and it often [170:26] requires polypharmacy and periodic [170:28] hospitalization. So, the news isn't [170:30] good. [170:31] Um, but at least we can say ADHD is not [170:34] a cause of bipolar disorder. Most ADHD [170:36] children are never at risk for it, but [170:38] if there's a family genetic link to [170:40] bipolar, then that young child with ADHD [170:43] may also carry that link and that risk. [170:54] Okay, there are more than 400 studies [170:57] of the stimulants. [170:59] Uh there are additional studies of the [171:00] other drugs like atomoxetine. They're [171:02] all placebo-controlled. The placebo rate [171:05] in most studies is between 10 and 35%. [171:08] The rate of responders to the active [171:10] medication is between 55% and 92% [171:14] averaging about 75%. So, it's twice the [171:16] placebo rate. So, at this point, we can [171:19] be assured from these randomized [171:21] placebo-controlled studies that the [171:22] medication has a real effect, not just [171:25] an effect of psychological [171:26] suggestibility [171:28] as the placebo effect might suggest. So, [171:31] all I can tell you is those studies have [171:32] been done. They've been done repeatedly, [171:34] and we can be assured this is not a [171:36] placebo effect. It doesn't mean there [171:37] isn't a little bit of a placebo effect, [171:39] but most of the effect is clearly that [171:40] of an active agent.