wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

hellipa challenge

Perspective of this workshophellip

ldquoTop ndash downrdquo dysfunction

ADHD Executive dysfunction

ldquoBottom - uprdquo dysfunction

Central auditory processing problems Sensory processing problems

Whatrsquos the kidrsquos deal

This Dense Pudding What Does Dopamine Feel Like Why You Arenrsquot Getting Exactly What Want All the Time Lend Me Your Brain

Overview

This Dense Pudding

Normal and Abnormal Sensory Processing and Attentional Functioning

Sensory Processing Disorder

S ensory In tegration

S ensory D iscrim ination

S ensory M odu lation

S ensory D etection

Sensory Integration Terminology

Sensory Processing

Developmental considerations Auditory Visual Tactile Proprioceptive Vestibular Motor

Sensory ProcessingIntegration Disorder and DSM-V

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Perspective of this workshophellip

ldquoTop ndash downrdquo dysfunction

ADHD Executive dysfunction

ldquoBottom - uprdquo dysfunction

Central auditory processing problems Sensory processing problems

Whatrsquos the kidrsquos deal

This Dense Pudding What Does Dopamine Feel Like Why You Arenrsquot Getting Exactly What Want All the Time Lend Me Your Brain

Overview

This Dense Pudding

Normal and Abnormal Sensory Processing and Attentional Functioning

Sensory Processing Disorder

S ensory In tegration

S ensory D iscrim ination

S ensory M odu lation

S ensory D etection

Sensory Integration Terminology

Sensory Processing

Developmental considerations Auditory Visual Tactile Proprioceptive Vestibular Motor

Sensory ProcessingIntegration Disorder and DSM-V

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ldquoTop ndash downrdquo dysfunction

ADHD Executive dysfunction

ldquoBottom - uprdquo dysfunction

Central auditory processing problems Sensory processing problems

Whatrsquos the kidrsquos deal

This Dense Pudding What Does Dopamine Feel Like Why You Arenrsquot Getting Exactly What Want All the Time Lend Me Your Brain

Overview

This Dense Pudding

Normal and Abnormal Sensory Processing and Attentional Functioning

Sensory Processing Disorder

S ensory In tegration

S ensory D iscrim ination

S ensory M odu lation

S ensory D etection

Sensory Integration Terminology

Sensory Processing

Developmental considerations Auditory Visual Tactile Proprioceptive Vestibular Motor

Sensory ProcessingIntegration Disorder and DSM-V

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ldquoBottom - uprdquo dysfunction

Central auditory processing problems Sensory processing problems

Whatrsquos the kidrsquos deal

This Dense Pudding What Does Dopamine Feel Like Why You Arenrsquot Getting Exactly What Want All the Time Lend Me Your Brain

Overview

This Dense Pudding

Normal and Abnormal Sensory Processing and Attentional Functioning

Sensory Processing Disorder

S ensory In tegration

S ensory D iscrim ination

S ensory M odu lation

S ensory D etection

Sensory Integration Terminology

Sensory Processing

Developmental considerations Auditory Visual Tactile Proprioceptive Vestibular Motor

Sensory ProcessingIntegration Disorder and DSM-V

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Whatrsquos the kidrsquos deal

This Dense Pudding What Does Dopamine Feel Like Why You Arenrsquot Getting Exactly What Want All the Time Lend Me Your Brain

Overview

This Dense Pudding

Normal and Abnormal Sensory Processing and Attentional Functioning

Sensory Processing Disorder

S ensory In tegration

S ensory D iscrim ination

S ensory M odu lation

S ensory D etection

Sensory Integration Terminology

Sensory Processing

Developmental considerations Auditory Visual Tactile Proprioceptive Vestibular Motor

Sensory ProcessingIntegration Disorder and DSM-V

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

This Dense Pudding What Does Dopamine Feel Like Why You Arenrsquot Getting Exactly What Want All the Time Lend Me Your Brain

Overview

This Dense Pudding

Normal and Abnormal Sensory Processing and Attentional Functioning

Sensory Processing Disorder

S ensory In tegration

S ensory D iscrim ination

S ensory M odu lation

S ensory D etection

Sensory Integration Terminology

Sensory Processing

Developmental considerations Auditory Visual Tactile Proprioceptive Vestibular Motor

Sensory ProcessingIntegration Disorder and DSM-V

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

This Dense Pudding

Normal and Abnormal Sensory Processing and Attentional Functioning

Sensory Processing Disorder

S ensory In tegration

S ensory D iscrim ination

S ensory M odu lation

S ensory D etection

Sensory Integration Terminology

Sensory Processing

Developmental considerations Auditory Visual Tactile Proprioceptive Vestibular Motor

Sensory ProcessingIntegration Disorder and DSM-V

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Sensory Processing Disorder

S ensory In tegration

S ensory D iscrim ination

S ensory M odu lation

S ensory D etection

Sensory Integration Terminology

Sensory Processing

Developmental considerations Auditory Visual Tactile Proprioceptive Vestibular Motor

Sensory ProcessingIntegration Disorder and DSM-V

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

S ensory In tegration

S ensory D iscrim ination

S ensory M odu lation

S ensory D etection

Sensory Integration Terminology

Sensory Processing

Developmental considerations Auditory Visual Tactile Proprioceptive Vestibular Motor

Sensory ProcessingIntegration Disorder and DSM-V

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Developmental considerations Auditory Visual Tactile Proprioceptive Vestibular Motor

Sensory ProcessingIntegration Disorder and DSM-V

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Sensory ProcessingIntegration Disorder and DSM-V

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Whatrsquos the kidrsquos deal

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Whatrsquos the kidrsquos deal

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Strategies

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo

ldquobottom uprdquo

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Regulatory-Sensory Processing Disorders

Treatment ldquotop downrdquo ldquobottom uprdquo

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Central Auditory Processing Disorder

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

bull Auditory discrimination (samedifferent)bull Auditory closure (fill in missing bits)bull Auditory localisation (locate source of sound)bull Auditory performance with degraded acousticsignalbull Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Central Auditory Processing Disorder

CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors sound localization and lateralization auditory discrimination auditory pattern recognition

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Central Auditory Processing Disorder

- Poor communicator (terse telegraphic) - Memorizes poorly- Hears better when watching the speaker - Problems with rapid speech - Interprets words too literally

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Central Auditory Processing Disorder

- Often needs remarks repeated - Difficulty sounding out words- Confuses similar-sounding words- Difficulty following directions in a series - Speech developed late or unclearly

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

CAPD or ADHD

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Whatrsquos the kidrsquos deal

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Strategies

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

(C)APD

Treatment ldquotop downrdquo ldquobottom uprdquo

X

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Treatment for CAPD

Environmental modifications

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Treatment for CAPD

Compensatory Strategies

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Self-assessment

>

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Increase salience

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Attention Deficit Hyperactivity Disorder

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

(85 ndash X) x 365

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ldquoIrsquom gonna eat all the gum and candy I wantrdquo

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Core symptoms

Inattention distractibility

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Core symptoms

Hyperactivity impulsivity

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

hellipand the rest of the criteriaB Onset before age 7C Impairment in 2 or more settingsD Significant functional impairmentE Not better accounted for by another

mental disorder

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Functional impact of core symptoms

Arousal alertness Mental effort Determination of saliency Focal maintenance

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Functional impact of core symptoms

Satisfaction control Previewing Inhibition Tempo control Self-monitoring and correcting

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise Specifed

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Subtypes of ADHD

ADHD predominantly inattentive type ADHD predominantly hyperactive type ADHD combined type ADHD Not Otherwise

Specifed

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Common comorbidities with ADHD

Learning disorder Behavioral disorder Anxiety Depression Substance abuse Sensory processing and auditory

processing challenges

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ADHD and girls

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ADHD and women

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ADHD and women

More tasks More diffuse More parental responsibility Less likely to have an ldquoexecutiverdquo

partner Less likely to have assistants at work Less likely to focus on a narrow area More likely to feel shame about

disorganization

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Executive FunctioningAn Overarching Theme

Sensory Processing Disorder Central Auditory Processing

Disorder ADHD and Executive Dysfunction

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

The Executive Functions

Internalizing speech Previewing

Prioritizing Tempo control Inhibition

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

The Executive Functions

Determining salience (whatrsquos in it for me)

Blocking out distractions Self-monitoring and correcting Certain aspects of memory learning

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Appropriate expectations

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Age-appropriate expectations

Preschool 1-step errands Chores with cues Basic inhibition

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Age-appropriate expectations

K ndash 2nd grade 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules inhibit no grabbing

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

3rd ndash 5th

Simple shopping list Keep track of personal items Longer homework assignments Simple project planing Keep track of variable daily schedule Save money Inhibit and regulate even wo teacher present Manners Simple delayed gratification (phone)

Age-appropriate expectations

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

6th ndash 8th

complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict

Age-appropriate expectations

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Teenage ndash mid 20s Independent with assignments Make adjustments based on feedback Longer term goal setting Managing leisure time Inhibit reckless behavior Easily walk away from provocation Say ldquonordquo to fun activity if other plans

already made Take othersrsquo perspective

Age-appropriate expectations

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ldquowhat isrdquo vs ldquowhat could berdquo

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Inter-connectedness of systems Cortico-striatal system for example

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Strategies

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Pharmacotherapy

X

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Behavioral Supports

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A B C

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A B C

behavior

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A B C

consequences

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A B C

antecedent

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A B C

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A B C

antecedent

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A B C

antecedent

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

easy hard

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A B C

consequences

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

R P

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

+

-

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

R+ P+

R- P-

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Time Out

Select target behavior Set place Determine how much time Dress rehearsal Measure the time Withdraw attention Establish the cause and effect

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Token economy

Good balance Precursor to adult reinforcement system Lots of work to do well Even more work to set up well

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Intrinsic motivation

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A B C

consequencesX

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A B C

behavior

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Metacognition

Metacognitive knowledge Metacognitive strategies

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ldquoLend Me Your Brainrdquo

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

What Does Dopamine Feel Like

The Physiology of Motivation and Reward

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Preferred States What Does Dopamine Feel Like

1 Great experience2 Kodak moment3 The feeeeling

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

David D Nowell PhD189 May Street

Worcester Mass 01602DrNowellcom

PREFERRED STATES INVENTORY

wwwLulucom

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Identify 20 peak experiences For each peak experience identify the

highlight moment ndash the snapshot Go to the visceralhellipwhat was the feeling

of that moment Name it Check the 20 peak moment-feelings for

clusters groupings There will probably be 4 or 5

PREFERRED STATES INVENTORY

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Find a word a label for each of the groupings

Check for accuracy (ldquogutrdquo check) Those are your preferred states your

ldquovaluesrdquo ways that you really like to feel

Now you know your motivationhellipuse this knowledge to review your daily activities and planning

PREFERRED STATES INVENTORY

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

PREFERRED STATES INVENTORY

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Broaden and Build

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ldquoNeuroMalleabilityrdquo

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Why You Arenrsquot Getting Exactly What You Want All the Time

The Brainrsquos Reward and Planning System - And How It Breaks Down

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ldquowhat isrdquo vs ldquowhat could berdquo

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

ldquowhat isrdquo vs ldquowhat could berdquo

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

The reward-and-planning system

Anticipate goal Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Alicia R Ruelaz MD ldquothe biggest issue for me and others Ive seen has been maintaining motivation between the excitement of setting a goal and not losing interest before it is completedrdquo

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Jacy a freelance artist from Connecticut I get so excited about a new idea I forget the zeal that I had once felt for an old one Thus creating my inevitable idea graveyardldquo

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Juzer ldquomy biggest problem is that I want to do everything all at oncerdquo

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Inna ldquoI just get blank I usually start sitting more slouched hold my head with my left hand hellipyou freeze and instead of being able to think of alternatives you start thinking to yourself that you cannot find a logical answer and you are tempted to avoid it as if it poses a threat somehow to yourdquo

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Lend Me Your Brain

Supporting Clients with Executive Dysfunction

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Hank ldquoI have things I need to do to improve my marriage my health and my financial situation but I honestly believe that I have zero chance of actually making any of those three things actually get better rdquo

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Alice a oach from Long Island The difference between a dream and a goal is a plan It is the myriad of steps BETWEEN point A and point B that fail to happen That is why a coach can be so important to folks with ADHD A coach can help the person develop a step-by-step plan and help the person decide which steps they can amp will complete (the exciting ones) and which steps they are best off hiring or asking someone else to do (the boring ones)

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Identify tasks Sequence problem-solve Block out distractions Get the reward

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Anticipate goal (state) Working memory Insight Alexithymia emotional intelligence Disconnect from values Diminished options Overly influenced by externals

Too busy with current activity

Field dependent

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Identify tasks Working memory Intelligence development Overly conventional thinking Insight Emotional intelligence

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Sequence problem-solve

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Sequence problem-solve Verbal working memory Nonverbal working memory Reconstitution Understanding of causality Self-efficacy Coping Learned helplessness

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Block out distractions

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

The best defense against the manipulation of our attention is to determine for ourselves ndash in advance - how we want to invest it

- E Goldberg

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Block out distractions Field dependent (sensitive to novelty) Saliency Working memory Easily discouraged

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Get the reward

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Ways the reward-and-planning system can go wrong

Get the reward Satisfaction control Picked wrong task Picked wrong goal (ldquostaterdquo) Sociopathy

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Instant gratification vs

executive gratification

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A B C

behaviorx

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Self-Talk Proficiency

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Self-Talk Proficiency

bull -ldquoHow are you going to know when to be readyrdquo

bull -ldquoHow are you going to stop yourself fromhelliprdquo

bull -ldquoWhat is your goalrdquo bull -ldquoWhat do you want it to look likerdquo bull -ldquoHow long do you think it will

takerdquordquo

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Self-Talk Proficiency

bull -ldquoHow are you going to know what you needrdquo

bull -ldquoHow are you going to know what is most importantrdquo

bull -ldquoHow are you going to decide what to do firstrdquo

bull -ldquoHow will you know when you are donerdquo

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Self-Talk Proficiency

bull -ldquoHow will you continue when you are tiredrdquo

bull -ldquoHow did that work outrdquo bull -ldquoHow long do you think that tookrdquo bull -ldquoWould you do anything

differentlyrdquo ldquoWho will be the first person to notice

thathelliprdquo

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Match the Picture

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Distraction Delay Training

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Executive Estimates Training

X

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Learning Time

What is the ldquofeltrdquo experience of time What is the ldquofrontalrdquo aspect of time

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Learning Time

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Learning Time

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Learning Time

Theres no such thing as procrastinationhelliptherersquos just choosing And choosing again

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Asking two questionshellip

Am I having fun now And is this what I set out to do

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Am I having fun nowIs

this

what

I se

t out

to

do

bullYesbullYes

bullNobullYes

bullYesbullNo

bullNobullNo

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Am I having fun nowIs

this

what

I se

t out

to

do

bullFunbullOn-task

bullNot funbullOn-task

bullFunbullNot on-task

bullNot funbullNot on-task

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Key Features of Video Games

Clear expectations Behavioral specificity Build on small changes in behavior Irrelevant behaviors ignored Reward appropriate behavior and punish

inappropriate behavior ndash never reverse this

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Key Features of Video Games

Always follow up on rules no exceptions Consequences are immediate Punishment is mild Stimuli are exciting and multi-sensory Conduct expensive and time-consuming

focus groups to determine what really ldquograbs lsquoemrdquo

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow et al 2004

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Increase salience

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Increase salience

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Quarterly QI review

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

The post-mortem

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Your 1 Organizational Tool

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Your 1 Organizational Tool

Yoga read

Staff meeting

Planningsession

Phone calls

billing

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Your 1 Organizational Tool

Vh jeff w puritan oilVc kate re brimfieldTC umass dermatology Spoke w cindy 508 8564000

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Your 1 Organizational Tool

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

Learn French

Stop smoking

Be a better spouse

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

The ldquoBig Fiverdquo

Daily focus time Valuesmotivational clarity Nutrition Movement Connection

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

A CHALLENGEhellip

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell

wwwDrNowellcom

Lend Me Your BrainPractical Strategies for Managing ADDADHDExecutive Dysfunction and Processing Disorders

DavidNowellSeminars

DavidNowell