REMEDIATION STRATEGIES WITH NEUROPSYCHOLOGICALLY-BASED DIFFICULTIES
The following remediation strategies for neuropsychologically based difficulties will benefit those with ADHD, widely considered a neurologically based impairment.
These strategies are adapted from Morse, P.A. and Montgomery, C.E., Neuropsychological evaluation of traumatic brain injury, in R.F. White (Ed.) Clinical Syndromes in Adult Neuropsychology: The Practitioner's Handbook. The Netherlands: Elsevier Science Publishers B.V., 1992)
Sustained Attention and Concentration Problems:
These problems are defined as the ability to remain focused on tasks or new information for an adequate length of time. They may require concentration, or active mental effort, versus passive attention.
1. Verbal mediation-this is the use of self-talk or talking aloud to keep focused on a task.
2. Write down to brief lists of what to focus on for you or your child to use as a reference.
3. Repeat instructions frequently, keeping them simple and concrete if necessary
4. Reduce the rate of presentation for any new information; make sure that information presented was comprehended before moving on.
5. Break tasks down into smaller, simpler steps. This is particularly useful when doing long-term projects in school or at work. Projects may have to be broken down into daily assignments.
6. Use frequent breaks between new batches of material.
7. Use rest periods frequently; determine the length of time you or your child can optimally function (for some it can be as little as five to ten minutes) and take brief rests (one to two minutes) in between.
8. Avoid lengthy, monotonous tasks.
Selective Attention is defined as the ability to focus attention on the most important information or stimuli available.
1. Reduce external sources of stimulation. Work in a quiet, nondistracting environment. Turn the TV and radio off.
2. Use verbal mediation (see above) to keep you or your child focused on the task if this helps. For some individuals, it may be even more distracting.
Alternating Attention is the ability to shift attention from one focus to the next and back again.
1. Use verbal mediation to direct attention to a new task.
2. Role-play situations (e.g. while at home pretend you are on the work site or have your child pretend they are in school and change focus from one task to the next). Use over practice.
Divided Attention is the ability to divide or split attention between two competing stimuli or tasks.
1. Allow extra time for tasks.
2. Remove the demand for divided attention by limiting task demands to one activity at a time.
3. Practice dividing attention between competing tasks.
Executive Functioning Problems
" Executive functions" are ones, which enable an individual to manage their behavior and task completion. The following executive function problems, and strategies to remediate them will be addressed in this article; 1) Problem recognition 2) Goal formulation/hypothesis generation 3) Planning.
This is the ability to identify the existence of a problem. Some children and adults with ADHD have difficulty with this executive function issue. Sometimes, this occurs because of impulsiveness (acting before thinking). If this is the case, reducing impulsivity via response delay tactics such as relaxation training, counting to 10 before beginning something, or practicing choosing between numerous possible responses may all be of help. Another possible intervention is practicing or role-playing problem situations in anticipation of issues that are likely to develop. Another intervention may be developing and practicing more than one possible solution to problems before acting.
Goal Formulation/Hypothesis Generation
This is an individual's ability to set a goal and develop ideas to solve the problem. If this is a problem for a child or an adult, practicing idea generation strategies can be beneficial. Increasing the individual's awareness of this issue as a problem for them and helping them to develop a list of possible ideas or goals on either a daily, weekly, or monthly basis can be of help. Providing additional structure for the individual can also help with this problem. Finally, placing the individual with greater supervision or a limited amount of potential problems that need to be practiced can be helpful. This means engaging in active limit setting for both children and teenagers.
This is the ability to plan multi-step approaches to problems. It is also the ability to plan and anticipate consequences of actions. Planning is an action that is a difficult undertaking for many ADHD individuals particularly if they are impulsive. One thing that can be done is practicing planning with familiar tasks such as cooking a meal. Help to make the individual aware of planning steps that are necessary for cooking even a simple meal.
Generalize this concept to other issues like cleaning a room or doing homework. Each step must be explicitly outlined even if it seems obvious to you. Practicing this process by making a game of it can be helpful. Having the individual use an outline, list, or flow chart that is developed before hand helps them to recognize necessary planning and understand steps. Listing potential problems at each step can also be of help.
Overall, it is critical to recognize that individuals with ADHD frequently have executive function problems. What can look like a lack of motivation, a lack of effort or not trying very hard may actually be part of the neurological dysfunction. You must work at taking a disability perspective
Executive Functioning Review
Let's take a minute for a brief review. The individual executive functions most commonly associated with difficulty in individuals with ADHD include; self-regulation (the ability to think before acting), shift (the ability to move from one task or activity to another without emotional distress), emotional control (the ability to self regulated intense emotions), initiation (the ability to get started - sometimes seen as a lack of motivation), working memory (the ability to keep in mind something long enough to use it, at the right time), organization/planning (the ability to organize thoughts and apply them to future events), organization of materials (the ability to keep track of materials necessary for work and organize them so that they can be properly used), monitor (the ability to look back over completed work or behaviors and adjust them for improvement purposes).
Executive function has been described as being like the conductor in an orchestra. All of the individual functions described in previous newsletters such as sustained attention and concentration, selective attention, problem recognition, and planning as well as the individual functions yet to be discussed including, organization, initiation, self-regulation and self-monitoring, are like various instruments in the orchestra. Some of these individual instruments may be playing/working well, while others may need help (e.g. music lessons). The conductor, or the frontal lobe in our case, helps the individual instruments to work together to produce a satisfying result.
Your job, as the parent of a child with ADHD, is to find out which of the individual instruments is working well and which need "lessons", and then to pursue remediation (lessons) in any area that is deficient. There are some diagnostic checklists available to help pinpoint deficient areas of executive function without going through a complete neuropsychological exam. Your local psychologist, who specializes in ADHD, should be familiar with these.
The more efficiently each of the individual sections is working, the more successful the conductor (the frontal lobe) will be in helping them work together to produce a satisfying result. It is important to note, however, that a frontal lobe deficiency in any one area cannot be "cured", but remediation strategies can help improve function in a specific area as long as it is in place, much like a step stool helps a short individual reach a high shelf.
Initiation and organization are two executive functions that often casue difficulty for people with ADHD. As described above initiation is an individual's ability to begin a desired behavior. First, because in individuals with ADHD, this is often a neurological dysfunction (especially when oppositional behavior can be ruled out) is important to reframe the "lack of motivation" explanation often attributed to this by teachers and sometimes, parents as "poor initiation", a neurological disorder.
Second, sometimes individuals with ADHD have difficulty with initiation because the task appears too large. Breaking tasks down into smaller, more manageable, steps can improve their ability to get started. Third, an individual may need a "jump start" to begin tasks. This "jump start" may take the form of a parental reminder, or another external cue such as an alarm, a message on a note card or sticky, or simply maintaining a daily routine so that the same tasks (such as homework) are done at the same time each day.
Organization, is the ability to organize information or tasks so that they can be put to productive use. First, helping the individual to implement a "memory" book or organizational system such as a homework planner, day planner, or simply maintaining a daily routine can help with this problem area. Second, presenting information in a pre-organized manner and reviewing how you organized it can help an individual with the task at hand and will help them to learn how to search for organization in the future. This, of course, will take an enormous amount of repetition.
In trying to implement any of the suggestions, a reward system can be of significant help an increasing motivation.
Working memory and self-monitoring are two more executive functions that often cause problems for people with ADHD. Here are some possible solutions for managing these executive functions.
Working memory is your ability to keep something in mind long enough to act on it, at the right time. For example, if you ask someone to stop at the neighbors house on their way home and to retrieve their jacket and their socks they may either come home remembering only one item or, come home and then remember that they were supposed to stop and retrieve the two items. The individual is either forgetting what they're supposed to retrieve or remembering what they're supposed to retrieve at the wrong time.
Strategies, to improve this dysfunction, work best (as Russell Barkley says) at the "point of performance". This means that strategies that are in place at the exact time they are needed are the best option. In this case, the ideal strategy would be an electronic reminder (such as a Palm Pilot) that would beep at the appropriate time and provide a written message such as "pickup socks and jacket." The next best thing would probably be a watch timer which would beep the appropriate time to provide a written message. Other things come to mind include paging the person on a pager at the appropriate time, having a hand written message placed in view so that it would be seen at the appropriate time, or calling the person on their cell phone at the appropriate time. The worst strategy would be to rely on the individuals deficient working memory to remember what they need at the appropriate time.
Self-monitoring is the final executive function we will discuss. Self-monitoring is the ability to be aware of behavior and to analyze, monitor and adjust behavior according to needs. This is an ongoing process, we are all doing this all of the time.
Strategies used to help with this problem may include; 1) increase self-awareness and error recognition by asking the person to anticipate whether they will complete the task correctly and to write this down. Next, compare their actual performance with their anticipated performance and help them recognize the differences. 2) videotape someone performing their task and then view the tape together to recognize self-regulation and monitoring errors. 3) Help the individual to use "verbal mediation" or talking themselves through an activity. Develop some key phrases that they can use such as "am I doing what I need to right now?"
As one can see, taking a disability perspective is very important. Understanding that you or your child has a disability and that the deficits are not willful behavior is important to help maintain self-esteem and patience.