 How's everybody this morning? Thank you I'm Fred Hines. I'm the president and CEO of Clarity Child Guidance Center And it's my special privilege to welcome you to Clarity con 2014 a summit on children's mental health Ahead of you is a day and a half of informative and interactive presentations Today your keynote speaker will be dr. Ellen Brotten And we are so excited that she has flown in from Boston to join us and those of us who are here and you know Know about the humidity and all that she's been through a really long winter in Boston So she was very very happy to be here We're pleased to welcome our special post Luncheon speaker K. Warren who joins us from California. I suppose her weather is probably better than it is here To share her story and ministry We look forward to hearing from Kay Throughout the day, you will also have 15 breakout sessions to choose from Presented by some of our community's leading authorities on children's mental health Tomorrow we welcome dr. Steve Plisca for a keynote address and what promises to be an engaging panel discussion on Children's mental health and primary care providers There will also be a choice of three breakout sessions for you to attend. It's going to be a full day and a half for you Having this conference is important There is a critical shortage of psychiatrists and in particular child and adolescent psychiatrists Everyone across the nation is looking for solutions to provide care to the nearly 20 percent of children who will need our help Creating and sustaining this conference is but one way we can share knowledge together and help heal young minds and hearts as a result We intend to make this an annual event and would appreciate your input on topics and your overall conference experience We want to create a destination conference that is beneficial for anyone associated with children and adolescent mental health. I Would also like to ask you to join me in thanking the over 20 speakers presenters and panelists who will be joining us today and tomorrow There will be surveys following each session for you to complete and we would appreciate your opinions Please note. We will provide the CEU certificates After our final session tomorrow morning at 11 15 a.m. No sneaking out early Last year Clarity Child Guidance Center cared for nearly 8,000 children struggling with mental emotional and behavioral Disorders and as many of you know if we had the capacity There were many more kids we could have served Thankfully other organizations in San Antonio are there to provide services, but it's still not enough From beds to psychiatrists our community has limited resources I want to share with you for a second how Clarity Child Guidance Center is taking steps to address the gaps In January of this year. We opened our first Clarity Child Guidance Clinic in the West over Hills area on the west side of San Antonio This clinic has already provided 859 therapy appointments 633 psychiatry visits for over 200 children We've also provided 200 days of care through a new unique program. Let me try that again a unique program Designated or designed to prevent hospitalization. It's called day treatment or partial hospitalization That's our second partial hospital program We are also preparing to break ground on a campus expansion that will add an additional 20 beds to our existing 52-bed hospital When these additional beds become available next year We will have created a regional psychiatric emergency service for children with six of the new beds designated for psychiatric emergency services and observation That's to prevent the nearly 1300 children who annually visit a local ER Only to discover that psychiatric care is not available or only available after hours of waiting in the ER We continue to create awareness of the importance of children's mental health Through our one in five minds advocacy campaign We recently celebrated our first year anniversary of one in five minds and to date Over 1200 people have signed up to support increasing access to treatment for kids and their families struggling with mental illness We appreciate the work you all do to care for the one in five kids who are struggling with a mental emotional or behavioral disorder I trust you will find this next day and a half to be beneficial in increasing your awareness about topics and tools To support you as you work with your clients Before I introduce our keynote speaker a few important things to know about the conference First this is the coronado room. This is where you will hear the keynote speakers Have breakfast again tomorrow Hear from our post lunch speaker k warren today and return for ceu certificates tomorrow After the last session ends No sneaking out early Second there are exhibitors in the lobby next door. You will pass them on the way to your breakout sessions We encourage you to visit with them and thank them for being here to support clarity con 2014 In your bag, you have an exhibitor card For each booth you visit you will receive a signature Everyone able to get all signatures can turn in their card tomorrow when you pick up your ceus We'll draw from the cards for free entries to clarity con 2015 third Breakout room names are outside the doors While you have time in your schedule to visit exhibitors We also ask that you arrive at the breakout sessions promptly And last but certainly not least Would you please join me to thank our presenting and luncheon sponsors a special. Thank you To tomorrow's keynote Keynote sponsor bear county Thank you to our k warren launch and sponsor today community bible church And thank you to the sponsor of this morning's keynote presentation methodist health care ministries And to now cast for streaming the conference live I'd like to now bring your keynote speaker to the podium Dr. Ellen Broughton is a renowned psychologist researcher television contributor and author Who works tirelessly in the field of pediatric neuropsychological and psychological assessment? Particularly in the area of assessing learning disabilities and attentional disorders Her career Her career expands it expands from today on right Her career spans over 30 years with a phd in counseling psychology From colorado state university A postdoctoral fellowship in child adult psychology at massachusetts general hospital and harvard medical school A master of arts in clinical psychology from the university of colorado danver and a bachelor of science from the university of wisconsin All which establish her as a leading authority in pediatric neuropsychology Dr. Broughton acts as both director of the learning and emotional assessment program at massachusetts general hospital And a professor of general child psychology at harvard university She specializes in pediatric neuropsychology And it is a member of the american psychological association and the american psychological society She has published research on multiple topics Dr. Ellen Broughton is not only a psychologist. She's an activist and philanthropist and a mother of two Allowing her to relate to a wide variety of the audiences Please join me in welcoming dr. Broughton to the podium Thank you so much for that very kind introduction. It's really such an honor and a privilege for me to be here today Um in support of this wonderful wonderful organization. Um, I should tell you to um A few little housekeeping details first and I am going to try and keep some time available for questions So if you have questions as i'm speaking drop them down because I hopefully will have time to answer them at the end And what I'd like to do today is to give you information that will Not just educate you, but hopefully it will get you to think maybe a little bit differently about the kids that you work with And I should say that the topic of my presentation Uh was kind of broad so when I sat down to sort of put together this talk I thought wow, I really gave myself a lot of leeway as to what to talk about today And I started to think well, where should I start? So I I'm going to start by just giving you some facts and I know One of your slogans is one in five children, but when we look at population over the lifespan It's actually even mental illness and psychiatric and behavioral disorders over the lifespan are even more than one in five It's one in four when we look at lifetime prevalences Um, so it's a big problem all of you know that already But what's important to think about is that for half of the cases throughout the lifespan Half of them start before the age of 14 meaning out of all the psychiatric and behavioral and emotional Disorders that we see over the lifespan Half of those cases started before a child was even 14 before they even got into high school And as you probably know There is um The third leading cause of death among young people ages 20 10 to 24 is suicide So this is a big problem. So as I was sitting there thinking of me What do I want to focus on given that this is a these are huge issues to think about I thought well, I'm going to I'm going to focus on three different things And all things that come out of either my own research or research in the clinics with the where I work at mass general and Harvard medical school So the three things I want to touch on today are first the role of shared risk factors Which I'll explain to you in a minute and I want to focus on in a couple of ways Executive functions, especially organization and processing speed I want to talk a little bit about resiliency and what that means For the kids that we work with and then I want to talk a little bit about collaborative problem solving So what do we do for the kids who have? Great risk who aren't resilient. What are some ways of helping them and treating them? So first let me just start by talking about what are the most Common types of problems that we see in kids when we think about childhood disorders We're really thinking about five broad categories specific learning disabilities Non-specific learning disorders developmental disorders mood disorders and behavioral disorders So when we talk about specific learning disorders, what we're really talking about are things like Reading math written expression a problem in a specific area of learning When we talk about non-specific learning disorders We're talking about those kind of disorders that aren't specific to a particular To a particular subject So non-verbal learning disorder is one of those kinds of disorders where kids have trouble with just the non-verbal problem solving in real life situations I also think of ADHD as a non-specific learning disorder A lot of people don't it can also go under behavior disorders and should But I sort of think of ADHD as a disorder that affects every area of learning I mean kids who have severe ADHD They're impacted in reading and math and written expression and social studies and art and pe So I kind of think of that as as a more broad kind of category in terms of learning disorders When we think of developmental disorders that includes the category of autism spectrum What we used to consider are called aspergers and mood disorders include things like depression and anxiety Behavioral disorders again things like ADHD, but also conduct disorder oppositional behaviors those sorts of things I want to just talk about two of these disorders that I just mentioned Just to kind of give you a little frame of reference what we're talking about because these are the two most common things You will see in schools The first one is ADHD and you probably already know this but ADHD is characterized by three different behaviors impulsivity inattention and hyperactivity And some kids will be more hyperactive impulsive Some kids will be more inattentive. Most kids have a combination of the two Now ADHD surprisingly only affects three to five percent of the population when we look at population based studies That might when I say surprising because it sometimes might seem if you're a teacher in a classroom But it's way more than five percent But that really is in the population the number of people who meet criteria for the disorder And over half of the kids with ADHD qualify for what we call a comorbid diagnosis Meaning they don't just meet criteria for ADHD They also meet criteria for a learning disability or anxiety or depression And I think this idea of comorbidity is one to really think about very carefully because i'm going to be bringing this up a number of times Because most of the kids we see aren't just ADHD or aren't just anxious Most of the kids we see are a combination of many things So it's hard for us as if you're in the classroom or in a treatment setting To just think about a child in terms of that one diagnosis It's much more complicated than that One other thing to just consider in terms of looking at how significant ADHD is on the population in general So when we look at um prison studies we find that depending on the study 25 to 40 of people who are incarcerated have ADHD So when you think about it, that's way more than the general population a huge risk factor for people The other uh disorder that you'll see Most prevalently in schools and in the general public is reading disability Sometimes the term dyslexia is used interchangeably. They're they're similar But um a reading disability is the most common and best studied of learning disabilities We know far more about reading disabilities and dyslexia than we do any other learning issue And most of the kids you'll see who have a learning disability 75 to 80 of them will be diagnosed with a reading disability So even though kids have math disabilities and disorders of written expression That only counts for about 20 to 25 of kids with learning disabilities And depending on this on the population studied Somewhere between 5 to 17 even up to 20 of a population could have a reading disability And you might ask well, why does that vary? Well, it's because we know that this kind of disability is genetically transmitted So depending on the population you're studying it may be more inherited than others So there are certain areas of country certain regions of the world where it's much more prevalent When you kind of think about it, if you're a classroom teacher and you have 20 kids in your classroom Chances are you'll have at least two kids in your classroom that'll meet criteria for a reading disability Now in terms of my clinic at the hospital like um Fred was saying I direct a program called the learning and emotional assessment program which we refer to as LEAP And to give you a sense of the kinds of kids who are coming into hospital based settings Very much we see a lot of kids with ADHD a lot of kids with learning disabilities Those are two main kinds of diagnoses that we see about a Quarter of the kids we see have an autism spectrum disorder Large proportion 25 have an anxiety disorder and others have mood disorders like depression Now you may be looking at this and saying well that adds up to a lot more than just a hundred percent Well, that's because most of the kids we see 57 percent of the kids we see have more than one diagnosis And again when you're thinking about the kids that you're seeing on a day-to-day basis Chances are about half of those kids Based on our studies and our studies are very similar to others that have been done Most of those kids will meet criteria for more than one diagnosis and in our sample 25 percent meet criteria for three or more diagnoses So again, we have to start thinking about kids in a much more complex way than than we generally have in the past One of the biggest challenges for parents of all of the when I showed you that last slide When we ask parents of all of those kids with all of those different sorts of diagnosis What is their biggest challenge? What they will say is disruptive behavior problems And disruptive behavior problems can be things like lying cheating Aggression verbal aggression physical aggression not surprisingly that's something that parents are quite quite troubled by So at our clinic about 31 percent rated their child as showing moderate or significant disruptive behaviors in daily life Meaning that they are saying that boy my child in daily life. Yeah, he may have ADHD or he may have a reading ability, but really what's getting me Really upset is this disruptive behavior these disruptive behavior problems And it's because they have really broad reaching kinds of consequences For instance the biggest problem that we find are social and peer problems So kids who have problems with significant disruptive behavior disorders have problems getting along with peers I guess it isn't super surprising They also have problems in daily living skills. They don't brush their teeth like they should they don't make their bed They can't get from one place to the next as we would expect them to be able to do School problems are also common that it actually might surprise you that it's only 47 percent of kids with these kinds of behavior problems have school problems And what really surprised us when we looked at this study is only 10 percent reported problems with parents So somehow even these kids who are having major behavioral issues somehow are getting along fairly well with their parents This is a really big and complex challenge for both the child and for the families And what we're finding is that Unidentified problems seem to be playing somewhat of a causal role in behavior problems What I mean by that is when kids aren't diagnosed with a condition or or it's not Identified that they are struggling with anxiety or they're struggling with a learning disability What we find is that That lack of a diagnosis that lack of being able to pinpoint what's troubling that child may actually be causing the behavioral issues themselves So in the kids that we see The kids at leap that we see who presented with disruptive behavior disorders Many of them had anxiety Many of them had co-occurring depression or mood concerns 20 percent had developmental disorders such as autism A number had had learning disabilities and then almost 70 percent had ADHD In many of these cases these kids went weren't diagnosed before they came to us So what we're supposing and what we're hypothesizing is that in many of these cases the actual what caused the behavior problem Was the underlying issues and i'm going to talk at the end a little bit about what we can do about that and how we can help kids with this We also know in addition to that that certain kinds of cognitive deficits may increase a child's risk for disruptive behavior problems So for example, if a child shows delays in language skills They're going to have a greater probability of having disruptive behavior problems I mean that just makes sense if you're not understanding what someone is saying You're going to have trouble actually behaving in the way they're asking you to behave A lot of them also had problems in pragmatics and social communication Meaning that they don't know the the rules for communicating with others Again that if they can learn those rules for knowing how to communicate with others They may then not display as many behavior disruptive behavior disorders Many of them showed problems in what we call set shifting meaning they can't get from one activity to the next without problems and a lot of them had problems with impulse control So when we look at all of those diagnoses that I showed you and think about these disruptive behavior disorders What we've learned is that there are problems that are common to all of these diagnoses So it's not just about the diagnosis itself But also about the skills that underline these underlie these diagnoses So things like executive function skills Language processing skills emotion regulation skills being able to think flexibly for example and to be able to be A social being to be able to think socially. How am I supposed to act in this way? What is somebody else feeling? What is their experience like and how can I change my behavior to match somebody else's experience? So one of the things we're thinking about in in our research is not just looking at Diagnoses themselves or disorders themselves, but looking at the underlying issues that are transmitted And when I'm talking about risk factors, that's what I'm talking about Is what are the risk factors for particular diagnoses? So we know for example that kids with ADHD have problems with executive function skills But what we're finding is so do kids with anxiety disorders So it's it may be actually that it's the Executive functions or these underlines. I'm just going to put this back here for one second those underlying disorders that are that are what's transmitted So we're doing some genetic studies at our clinic And they're fairly preliminary because you need a lot of a lot of kids a lot of families to do really good genetic studies But one of the things we're thinking about and some of the new research that's coming out in our clinics and and in other clinics is that Perhaps we've been looking in the wrong spot So we've been looking at for instance finding a gene for depression or finding a gene for ADHD or for anxiety And maybe that's not where we should be looking So we have in some cases found markers or gene markers for things like autism And dyslexia and that's that's been great and they've been very informative kind of studies But really when we look at it, for instance, some of the genes identified for autism They explain like maybe two or three percent of all kids with autism So what we're thinking about is maybe what we should be doing is looking Neuropsychologically looking at the underlying neuropsychological impairments that that occur across these disorders That perhaps that's what's transmitted Perhaps it's it's the underlining problem with organization or executive function And in one person it can come out as ADHD In another child it might look more like anxiety And this is kind of a different way of thinking about kids thinking about them not as their disorder But what the traits are what the skills are that they have that underlie that disorder Now we know for example in one of the studies that was done in our clinic that We looked at we looked at families that had a child with ADHD and we studied other people in the family Brothers sisters mom and dad and what was what we found and it's been quite robust in terms of our findings What we found is that other family members who do not meet criteria for ADHD still have problems with executive function skills So for example, billy in the family who has ADHD Has the impulsivity the hyperactivity the inattention we test him We can find that he's got problems with organization with executive function Um with processing speed And then we we look at a sister who's a good student and we test her and we find that there are some subtle issues With her as well. So that's what's Informing our thinking somewhat is that perhaps It's a gene that's transmitted that in some cases there's an environment and and um gene interaction That causes in one family member that gene to be expressed in the full blown picture of the disorder So that's kind of what this little Diagram sort of shows so for instance Neuropsychological impairments We know are inheritable and may share some of their genetic etiology with the disorders in which they occur So let me talk a little bit about executive function skills And you guys probably already know a lot about this But I thought I would mention it and I want to talk about two executive function skills in particular That we are finding are something that seems to be inherited Um, so just to get us on the same page So executive function skills very general term very hard to explain to parents Because it refers to a lot of different things it refers to things like Organizational skills the ability to focus one's attention as well as the ability to know where to focus one's attention And the ability to maintain attention And I also I always had to put in there to know where to focus one's attention because I hear all the time from parents And they say my child can't have ADHD he plays video games all day long And that really isn't good attention skills. They don't know where that's when it's not time to play video games Billy still is playing video games. That's actually more a sign of ADHD than it is a sign not of ADHD And it's also the ability of course to inhibit one's behavior So one of the things we assess in terms of looking at Kids with ADHD is we want to look at what's their focused attention like How well do they encode information? How well does information get in there in a way so that they can make it meaningful? We want to look at working memory skills and working memory isn't long term memory. It's that short term memory It's our memory scratch pad that gets us thinking about Okay, somebody gave you a set of directions to do Did you remember all three steps in the directions or did you only remember the first one or only the last one Kids with executive function problems have a tendency towards relatively weak working memory skills We want to look at also organization and then processing speed and and I'm going to talk a lot about processing speed because it's It's something that's kind of near and dear to my heart. First of all, I don't know if you guys are finding this but And I'll talk a little bit more about this in a second But I've I've been finding that over the years and I've been doing this for a long time I didn't realize it was quite 30 years that made me feel quite I was like wow, that's a long time But it's true What I've found is that over the years kids seem to be struggling more and more with just basic Processing meaning speed of processing and those of you who are familiar with Intelligence tests one of the things that we measure on an IQ test like the whisk is processing speed And we look at verbal memory and nonverbal memory And working memory and then also processing speed over the years Especially in the last 10 years or so I have found that kids seem to be struggling more and more with just the timing of having to do the particular task So processing speed for example on an IQ test is really how fast you can check something look at something and say Is that the same or different or how fast you can copy a code kids seem to be getting worse and worse at this And so and the other problem is that our world is just getting faster and faster So I'll come back to that in a minute So I've also I've already mentioned this somewhat But I'll mention it again that problems and executive functions are common to all of these Diagnoses, but the reasons for them might differ. So for example, let me give you an ADHD and anxiety. We know that both Disorders are associated with problems in executive function A child with ADHD may look at a problem and not know where to start in it So they may show disorganization because they don't even know where to start on the problem And they may just plunge in or they may not even touch it because they don't know what to do Or they may do some other kind, you know, you may ask them to solve a problem It's kind of up to them as to how to do it. They may just start talking about something else Whereas a child with anxiety will also show on tests Problems with organizational skills, but their problems under are underlined by problems with over attention to details So they may look at a situation or a problem and focus on one particular detail So they show problems with organization But the the actual reasons for them are different and the treatments for them would be different as well And kids with mood disorders and autism spectrum disorders and learning disorders Also have problems with executive functions for very different reasons kids with learning disabilities have problems Perhaps reading what they're supposed to do in a certain problem Kids with autism spectrum may have problems because they don't actually get the social Organizational structure of the situation and kids with mood disorders may just not have the energy to attack a particular problem If you're depressed or you may just not be able to engage in the problem-solving activity So the reasons for the problems may differ and the techniques for dealing with them would differ as well So i'm going to give you a little test here just to i want to just show you how we measure organizational Um organization and kids with ADHD and i'm this is comes from a test called the Hooper visual organization test and This test is a series of pictures and We have the child look at this or even adults look at this This is even used for adults and we say okay. Here's a picture and Of a puzzle and the pieces are all The puzzle are all kind of cut up and placed around this page Imagine what this would be if you put the puzzle pieces together. What would it be? So it helps them or it helps us understand. How are they looking at something that's kind of disorganized just strewn around a page and How do they then make meaning of it or make sense of it? Um, I won't put anybody on the spot, but does anybody know what it is This one's a hard one. In fact, it's the hardest one on this test. That's why I put this one down It's actually a shoe. Can you even imagine that it is? A shoe I know with the lace. You see that thing at the very bottom there. That's kind of the lace. It's actually the There are a lot of of items on this test that are really easy that I could have put up and you'd be like Oh, I know exactly what that is But um, this one actually I had trouble seeing it and what we did one time in the clinic Is we actually made a copy of this and cut it out and pasted it together to actually To see and it does actually make a shoe, but it is hard So that's one way we measure and there are many many ways we can measure organizational skills But I just want to give you a taste for this the other thing Is this how many people have already seen this kind of figure? Yeah, okay So this is one of our more sensitive tests for ADHD and Just organization in general because kids with ADHD tend to fail miserably on this test So take a minute on this. In fact, even if you want to take a second or two to go ahead and just draw it out What would it where would you start? I'll give you a second or two if you So it's called the complex figure. It's called the ray osterite complex figure and it for a good reason Because it is complex But I don't want to interrupt those of you who are actually trying to do this But when you look at this it's a child with ADHD would look at this and say oh my goodness I don't even know where to start a lot of them start over there on the very left hand side with that cross Which is like the worst place to start kids with ADHD often start in the middle of the page With the little cross and then run out of room to actually finish the the figure on the page If you look at this figure though One of the things you'll notice is if you start with the rectangle And put in the horizontal and diagonal lines it all kind of falls into place So people with good organizational skills will approach it that way Most of the kids I see do not so let me show you what a good A well organized figure will look like For those of you who are still drawing and want to So oftentimes I have kids and people who administer this test have kids and adults even Do this test using different colored markers so we can see how they approach the test Not just did they get it all right, but what was the order in which they did this so for example This one I started with the the black color So this person very well organized knew exactly how to attack this problem Started with the big rectangle see written in the black they put the horizontal and diagonal lines in And then boom everything else kind of falls into place Then they went to the red to the outside Then they put in some of the blue and then finished up with the green So it's actually a perfectly drawn figure because they started with the the rectangle now Take a look at this one. This is a kid a very very bright kid with adhd Who it doesn't look that bad. So I showed this to the parents and oftentimes I'll show this particular test to parents and they're they'll be like you you gave my child that test I can't do that. That's really you know, but um, and I showed this to the parents and they're like that's not bad at all But when you look at this, do you see how poorly organized it is? Do you see how this person started with? Actually started with the purple So they started over there with that purple cross Went around did the bottom then they came around to the blue and started around there And they there isn't even a rectangle embedded in this So a lot of times when I talk to parents about all right your child is struggling with organization Here's here's proof. Here's some in living color that they don't see they don't make sense of the world in the same way We do they they don't see that rectangle um, they kind of just sort of Just start and hope that they reach the solution at the end So it's not really a perfectly drawn figure. It's very compartmentalized when I was talking before about kids with anxiety disorders Oftentimes kids with anxiety disorders do very poorly on this test for a different reason like I was saying So kids with ADHD tend to plunge into a test like this and let me just give this a try And then they may or may not come out with the right Kind of solution people with anxiety disorders tend to over focus on the details. They tend to worry about Oh my gosh, there are all these little details. So they'll be just or their figures will look similar But again, it's for a different reason They'll kind of over focus on all these little details really being anxious about like get all these parts right Now here's a really bad Ray this child um was quite ADHD also had some other issues But you can see that for this child organizational skills are just not where They need to be and I think this was a 10 year old And so this child just doesn't even see the world in the same sort of way that We might be expecting him or her to and it's a child with normal intelligence too They just could not do this task at all that just gives you a sense for organizational skills And again, we're finding these sorts of skills are ones that tend to run in families Now the other thing like I was saying that I'm very interested in looking at his processing speed And I should tell you too that I'm I just finished writing a book that's coming out on processing speed called Bright kids who can't keep up and the reason there are two reasons why I this Subject is near and dear to my heart One is because like I said before I'm seeing more and more kids who are struggling with this issue I also have to say to you that I'm a I'm a mother And I have a son who's 20 now who has ADHD more the inattentive subtype ADD And he struggles a lot with processing speed So I was seeing this all day long and the clinic kids who are struggling to get their work done Teachers who are complaining, you know, this child can never get anything done And then I go home and do homework thought so when my editor of my Last book said, you know, what's the next thing you want to write about? Should it be working memory? Should she came up with all these different ideas? I'm like processing speed So it's I just think it's one of those things that tends to give parents and teachers the most trouble in day to day life So anyway, so what is processing speed? So processing speed is the speed at which we can perform basic cognitive operations It includes a lot of different things how quickly we perceive information how we can Allocate our attention. This is what I need to pay attention to this is how quickly I can move to that It includes our ability to kind of chunk information. So when we look at something and We're trying to process it. Can we kind of chunk it into information so it gets into our brain? It includes things like our long-term memory access So how quickly we can access information and long-term memory retrieve it how quickly we can respond correctly to a question And then also how quickly again we can access our long-term memory storage So I don't know if this is something that you guys seem to Struggle with a lot, but I do hear from teachers that this seems to be You know this child can never get anything done a lot of times That's the main referral question is not he's struggling with reading or he's not paying attention But he's the last one done and I don't know how to help this kid Um, I also get questions a lot from parents about what this is and it's really hard Even I just wrote a book on this. It's still really hard for me to explain And in part because we there's no single brain region that's been identified as what causes processing speed So it's really a more complex kind of problem that That uses multiple regions of the brain So again, um processing speed It's basically how long it takes someone to get something done in a certain period of time And it's always been thought of as an executive function skill It still is thought of as an executive function skill And again these skills are things like goal setting planning prioritizing But I kind of think as processing speed is maybe a little bit different Maybe it's something that actually underlies our executive function skills. So for example If Executive function is the car processing speed is the engine So again looking at some of these issues like goal setting planning organizing if we don't have a good engine It's hard to get moving on any of those other kinds of Issues or problems So for example having a faster engine or a more powerful engine means the car can go faster So good executive functioning depends on the quality of the engine So if we've got a more efficient engine, it allows our car to function at a higher level of efficiency So now I don't really know that much about cars. I had somebody asked me one time Does that mean that it's like the horsepower of the engine or the torque? I don't really know But it is something that it does seem to to um You know like if we have a better engine, it doesn't really matter what the car with the outside of the car is like We can still move quickly So the other issue that I think I've alluded to this earlier Is that processing speed is becoming so much more important in our fast-paced world So we kids just have so much more to take care of so much more to worry about so much more to do and the the Requirements of their time are vast So when we're talking about things like processing speed and thinking about a child Maybe in the classroom or in a clinic who's just not quite getting it quickly enough It can actually Encompass a lot of different things and not everybody has problems in each one of these areas But most have problems in more than one So the three major issues that we're talking about when we're talking about processing speed or visual processing Verbal processing and motor speed So visual processing can can be just as simple as how quickly our eyes perceive information and relay it to the brain How quickly our eyes dilate to light? Now we know that people who have problems in visual processing have problems in these areas People with slower visual processing have more car accidents They have more difficulty looking up phone numbers They have difficulty making change in a in an interaction and they have different difficulty finding something on a shelf now these studies that i'm Referring to have all been done with elderly people who are losing their executive functions who are slowing down And so when you think about that makes sense like if grandma or great grandma is having trouble that she's slowing down She's having trouble finding a phone number. She's having trouble making change We give grandma plenty of time and leeway to do that because we kind of understand. Well, she's just slower than average She's older. She's slowing down We don't always accord the same kind of time to kids who have problems in this area What we tend to do is to say speed it up. Hurry up. What's taking you so long So we need to kind of think about kids who who fall in this lower end of the spectrum on processing speed as kind of being more like Grandma who's having more trouble, you know, we need to give them more time to be able to process these sorts of things Also, when you think about car accidents where there are some studies being done at the hospital I'm not doing them looking at adhd and car accidents and and reaction times And we might be finding out that that kids also who have trouble with processing speed have more car accidents We know kids with adhd who go untreated have more car accidents So this might be it's not a reason to not give these kids licenses, but it might be a reason for us to intervene Verbal processing is how quickly we can hear something and then react to it It includes things like making meaning from what someone has said and then reacting to it So you think about these kids in the classroom It means the teacher's asking a question and they're not the first ones with their hands up In fact, they're still thinking about the last question by the time the next question has already been answered in a Setting like in a therapy session They may be the kind of child who just doesn't quite process the information the questions that the therapist might be giving them quickly enough This is linked to when we look at studies done again on adults because we don't really have any studies on processing speeding kids yet It's linked to problems with nearly all aspects of verbal memory And comprehending instructions So we think it's linked to verbal memory because the longer it takes somebody to process information The more likely it is they're losing that information So it's not getting into verbal memory as quickly as it should because they're not encoding it quickly enough And the other thing that includes that processing speed includes is just kind of simple motor speed Placing pegs in a board copying A series of numbers and even being able to just read a paragraph Which includes again when you think about it visual processing verbal processing as well A lot of the tasks that we do to to measure processing speed include multiple areas It doesn't I should say though in terms of motor speed We're not finding that these kids are necessarily slower on the soccer field That this doesn't tend to We at least we're not finding it yet This doesn't tend to to go into sort of gross motor skills And it may be that the the way that kids participate in gross motor skills are very you know, it's kind of one thing It's either the hockey in the on the hockey puck or the The soccer ball so it actually sports may Be a good thing for some of these kids because they only have one thing to keep track of that Maybe why we don't necessarily find problems in processing gross motor processing speed in kids who have fine motor processing speed So basically it's complicated What would when we're thinking about processing speed? We're thinking about things like being able to scan for the right kind of detail Understanding visual symbols being able to do something in the right order Being able to quickly learn a routine Being able to work quickly methodically nowhere to start Think back to that design that I showed you the ray osterite So a child with slow processing speed may just kind of look at that for you know longer than they should And again not know where to start And it takes them longer. They don't understand kind of the underlying visual Organizational structure of the task and can't then work quickly and methodically So when you think about the kinds of tasks that kids are asked to do in the classroom A lot of them are complicated. A lot of them involve understanding detailed visual symbols Even something as simple as copying notes from a board Being able to scan and know what it is that I'm supposed to write down or what is it that the teacher's saying that's important They're slower at being able to kind of sort through what the teacher is saying So i'm going to just talk a little bit just in case you guys are curious about How this processing speed actually happens in the brain So um a faster nervous system allows for us to more rapidly process information So And this may take you back. Especially if I show you this next slide to High school biology and if it brings back bad memories, I uh, I apologize, but basically Because and again because people ask I go what causes somebody to be slower because again You look at these kids and you think if they just would try harder. They would do better Again to kind of talking about my own home life. Sometimes I would just say to my son just start by picking up the pencil But even that takes a long time. Well, I don't know which pencil to pick up and I don't know where It's just they're just slower at everything and really it's it looks so much and I I find that dads have even the hardest time with this I shouldn't stare at a type like that but dads tend to be like if you just get it done He just has to do it, but really they are just slower at this and it's it happens in the brain So a lot of different things can Cause this one is just how big the nerves are in the brain And another thing is the myelin sheathing. So um, let me just show you this for a minute. So basically Nerve diameter can play a part in this. Some kids just have smaller nerve cells that may cause them to be slower There's also a coating and I don't know if Again, this might take you back to high school of college biology But there's a coating that runs along the axon that carries the impulses from one brain cell to the next And that's called the myelin sheath of the myelin coating and as kids grow that Coding develops over time. That's why kids executive functions improve over time because that gets better over time For these kids what we're thinking is maybe some of them have that a poor coating in that area of the of the cell And one of the reasons why we think that might be true is we know that in certain syndromes such as multiple sclerosis Part of the syndrome is that they're that myelin she starts to break down Well, what happens when for those people that coating starts to break down? They start to slow down They're it's associated with other things too like numbness and inability to walk But but one of the major things we find in ms is that people start to become slower. It slows the whole process down And so that's one of the hypotheses as well And then the other thing is is just how efficient and I don't have a pointer here But just how efficient the two cells communicate with one another And we're looking at this because we don't have any medications that actually address this We don't have anything that that can speed up the brain's processes So we you know, we have some medications like Adderall and Concerta and Ritalin They don't really Make a big effect in terms of how quickly the brain processes information Now it does help with attention And so we find that the more attentive kids are the better and quicker they are Always are if we know how we're going to proceed in a task. We can do the task quicker So in some of the ways that we're Proposing the kids can speed up Organization teaching them good executive function skills and those sorts of things can definitely help But we want to look actually at what happens in the brain so we can find treatments that actually might speed up that area of the brain We're still not there yet not really even close, but that's where that's where the research is going now So one of the things to consider is what kind of what these kids look like What kids with slow processing speed tend to look like and we thought I thought originally that most of these kids were just kids with ADHD Because you know when you think about the attentive kid in the classroom or in the Home setting, they're the child who's just like, huh, what? But what we found is that not this it's not synonymous. It's it's not the same Kids with ADHD. So these in in terms of our studies kids with ADHD Um, so the percentage of kids with slow processing speed who met criteria for ADHD was only 61% so Not every child with slow processing speed has ADHD nor does it work the other way When you look at this a lot of kids with reading disabilities have slow processing speed a fair number of kids with generalized anxiety disorders math disorders Bipolar disorder depression. So it's something to consider You know a fair number of kids and a lot of these issues have this particular Problem, so it's something to consider when you're working with kids is what's the tempo of this child What's their normal rate of being and when you're thinking about ADHD kids? That's definitely chances are better than average that they're going to have this problem But even when you're looking at kids with reading disorders and um anxiety disorders One out of five one out of four will have trouble in this and it's a big problem It's really something that has to be looked at in terms of treatment So in our clinic just to describe what these kids look like We studied kids from ages 10 I mean excuse me two to 20 and the average was about 10 and What we found is that they tend to this this kind of problem with slow processing speed tends to be more prevalent in boys And that might surprise you or it might not I mean we do know that almost every disorder we study is more prevalent in boys with the exception of depression So that may just be that's just one of those things that boys just tend to have more diagnosable problems It may also though be because boys are just slower at fine motor tasks And a lot of the way that we measure processing speed Is with fine motor tasks writing There also may be somewhat of a gender bias in teaching that may cause boys to be a little bit less May cause boys to practice these kinds of skills a little bit less You know, we tend to you know, if a boy has poor handwriting, it's like, ah, he's a boy Don't worry about it. But that may actually be affecting How they're performing on these kinds of tasks These kids also very interestingly have problems with social difficulties. They have major problems with language impairments So a child with slow processing speed Chances are very Strong that they have some subtle language problems. Not just problems Comprehending they may have even very decent Problem or a very decent performance on like for instance the whisk task Looking at verbal intellect, but they may have problems with for instance retrieving information from memory So they have these subtle language impairments A third of them had had delays in motor development in early childhood So when we see kids very early who have delays in motor development, it can be Chances, you know one out of three that they're going to also exhibit slow processing speed later on The vast majority runs some kind of educational program at IEP and again, it's not the same thing as ADHD So the kinds of problems that we see in processing speed deficits are things like an inefficient use of time Underestimating the amount of work and time needed to complete tasks. So this is something that I see all the time What's so ironic is that kids who have the slow processing speed tend to Think that it's going to take them a shorter amount of time to get things done So they they look at a problem and they're like, I've got that nailed. I don't need to get started on that That's only going to take me 30 minutes when really if it takes the rest of the class an hour It's probably going to take them 90 minutes to do it. But somehow they think that they're going to get done quicker Um, I and I just find this This to be universal Um, of course, slow work pace or failing to pace one's work Not being able to evaluate good strategies that would help them. So you give them a strategy You know, it's actually going to benefit them and they're like, uh, I don't think that's going to work Because I either, you know, they think they've already got it done or that They just don't think it's going to work So these kids really need to be proven to you really need to take them through step by step as to how it will help them Because most of the time they'll look at it and say it's not it's not Needed or it's not going to work And they have very limited awareness of problem solving and organizational strategies So it kind of goes along with that idea that they can't evaluate really good strategies Now in looking at these kids the one other thing I want to think about Is the role of resilience And I think it's important to look at this because this is a big kind of strategy when we're thinking about how to Help these kids not just kids with slow processing speed But all of those kids that I was kind of talking about Resilience is one of the things we're finding is is probably one of the biggest ways of Fostering resilience is one of the biggest ways of actually fostering better Performance better outcomes So resilience is is that ability for somebody to maintain personal and social stability despite adversity One thing to remember is that resilience is a process. It's not a trait We tend to think of it in our culture as something while there's a resilient person There's a non-resilient person and so you know, that's why that person did so well That's why, you know, she had a terrible life, but she wound up doing so well, but it's really not the case Yes, we're all born with certain personality characteristics that might make us more apt to be more resilient But it's really something that can be taught So we need to kind of think about preventative measures and also corrective measures So some of the elements of resilience are our biology like I alluded to that some, you know Sometimes we're just a little bit more better able to handle adversity But also issues in the family and the social environment One of the key features is attachment that happens first of course in the family But also attachment to schools and communities and churches also another big Important factor in resilience and awareness and I think that's something to really think about when we're thinking about Okay, how do we look at kids? How do we identify their problem areas? How do we make that part of their awareness of themselves and their own ability to self-reflect? So you know of course that kids today are Faced with a lot of different challenges that just makes this whole idea of resiliency even tougher So they're the family is changing. They're exposed to more violence at least more violence in the media They see every week. It seems like there's another school shooting. It's stressful for them Availability of drugs and alcohol and let's not even get into social media the kinds of issues that that brings up for kids especially kids who may have poor judgment or Maybe more impulsive or more apt to act out So it's much more difficult for them than it was than it was for kids 20 years ago most definitely And the risks are more debilitating and have bigger consequences for kids with learning disabilities again They don't always see what the consequences are of their actions So risk factors are things that are associated With an increased likelihood that someone's going to develop an emotional or behavior disorder And risk factors can be individual or they can be environmental So one of the things to think about when we're talking about risk factors And it kind of seems like a circular sort of statement But kids with learning disabilities just the learning disability in in of itself places them at risk For more emotional problems more social problems So Already kids with learning disabilities kids with behavioral challenges are already at greater risk for having more challenges for not being as resilient Yet there are some ways we can protect these kids And again that protect them in terms of building resiliency So that ability to spring back from adversity and for kids with these sorts of issues that we're talking about Their adversity may be their disorder themselves It doesn't necessarily have to be that they experience trauma or difficult upbringing although a lot of the kids we see have both So the kinds of things the protective factors are things like a good temperament Social competence so kids are just born more social Are more protected in terms of what life's going to throw at them Family factors like supportive families Families who set consistent kinds of rules and community factors like supportive school environments Community church positive relationships with significant adults And that's a very important kind of thing And i'll come back to that positive relationships with Significant adults in a minute, but I want to talk about this issue of self-awareness as a protective factor So I talked a lot about okay There here are some of the things we can identify that across disorders kids tend to struggle with And it's always a good thing for kids to know after a certain age depending on their level of understanding What it is they're struggling with it oftentimes can be very helpful for kids very comforting for them to hear that You have adhd so why you're struggling is because of this and this is you know It has a name that can be very helpful for kids But going further than that it can be really helpful to know Well, what does that mean for them that not every child with adhd is the same Not every kid with high functioning autism is the same In fact that the statement that we often use is when you've seen one child with autism You've seen one child with autism that everyone is so different So allowing Excuse me giving kids more self-awareness allows them to develop these sort of compensatory strategies Proactive strategies for achieving in school as well as for finding employment So kids who have better self-awareness are more likely to seek assistance when needed They're more likely to avail themselves of the kinds of educational and employment opportunities that build on their strengths And they also enter these kinds of opportunities knowing their weaknesses So a lot of times parents will say to me I don't want my child to know they have such and such or don't tell him that he struggles with working memory skills For example, but really the research shows the opposite effect that the more we can teach kids about who they are The better able they are to be resilient and to be successful So in order to do that one of the things that we found is is Most successful is to have early identification with educational psycho educational testing Neuropsychological testing that leads them to be able to adapt better They provides a roadmap for the child for the family and for the teacher And so because it has a significant impact on functioning and also self-concept and self-esteem So again, a lot of parents think like if you tell my child too much about his profile He's going to feel bad about himself But really the opposite tends to be true. It tends to increase self-esteem if it can be done in a way that's very You know, well here here are your struggles. Here's how we're going to fix them here are your strengths Those are the things to rely on And along with these kind of factors being able to provide intensive early remediation I know you all know that already And also the other important environmental factor is being able to provide good and effective transition plans during high school And that's something that's mandated by law. I don't find that we do a particularly great job of it in massachusetts I don't know how you feel here, but it's really hard to put good effective transition plans for high school students into place I think it's just an area that we don't know a lot about and I feel like that whole area of kids between the ages of like 18 and 24 sort of that black hole that what we call transitional age youth is really just that You know that difficult area that we just don't really always know how to treat and how to get them successfully into adulthood And a lot of parents will say Even the parents of kids who don't have problems will say they're having their trouble getting their child launched into adulthood I think it's just a problem that we're having So anyway In terms of also rebuilding resiliency So one one area is to get kids to know more about themselves to understand them better to look at some of these subtle executive function issues So that they know more about what is their own profile But the other thing that's been very well documented is the impact of a single adult So all it takes is one person in school So if we look at people who have overcome adversity and asked them in adulthood What was what was the thing that got you through the most frequent thing they'll say is the impact of one single adult It just takes one person to make a difference And it can be a minister. It can be a teacher. It can be somebody in their art class But that person believed in them and you know, we all can act as that single adult in a child's life So the person who says instead of if you only tried harder and put in more effort you would do better Instead being the person who says I know you're trying But I think the problem may be that the strategies you're using Or the strategies your teachers are using aren't the best strategies for you at this particular time And that doesn't get the child off the hook. That doesn't mean that well, then you don't have to do anything It's like we need to reassess here and figure out what's going to work for you And that actually helps the child realize well, it's not just me So if a child's having trouble learning to read and needs a different approach It can be very comforting for them to know. Oh, that's what it is I just need to have a different way of learning or a different kind of setting The other thing that really builds resiliency is finding an area of confidence So taking pleasure in in activities that they can find comfort in when things aren't going so well This kind of goes along with what I just said providing ample opportunities to assume responsibilities That make a contribution to the home because it provides them with Concrete proof that they can be successful So even the child who struggles paying attention in the classroom might be great In our class or they may be great in community activities. So that's that part of their Experience is proof to them that wait a minute the world's a bigger place and I can be successful in certain spots And again being able to give it also gives them these opportunities to learn skills for making better Choices making better decisions So one of the things to remember is that the essential ingredient of high self-esteem isn't just saying I'm really good at a lot of stuff It's being able to Believe that you have control over your environment being able to believe that okay What I do makes a difference what I my environment I can change what's happening Not everything but I can change I can affect change of myself and I can affect change in the world I live in and we tend to sometimes not we necessarily but our society tends to think of high self-esteem just comes from You did a great job. You're great. You're great with these kids. They know they're not great They know they can see this that wait a minute. I'm struggling What do you mean? Everything's great because it's not but providing them with opportunities that they can feel Self-sufficient and feel like they can make a change in themselves or others is what is that missing ingredient for them One of the most exciting things to think about when we look at kids with learning disabilities and behavioral challenges Over the lifespan if we can get them to college the evidence for these kids is really remarkable Meaning that when they get to college there is they're shown to be more resilient than college students who don't have learning disabilities So for example studies have shown that kids with learning disabilities report higher levels of initiative in everyday problem-solving Better need for achievement So that might be surprising to you that these kids are more resilient than others in college Now you might say well It could be because you're only looking at the kids with learning disabilities who made it to college and that is true But when you think about the kids who have the deck stacked against them from the beginning The fact that once they get into college, they look better. They look more resilient That's an important fact to remember So that's our you know kind of thinking about the long goal is that we're really thinking about launching these kids into college settings So we don't really know so we don't really know why this is but we do know that Non-learning disabled college students report greater feelings of stress than kids with learning disabilities And this is particularly true for kids who know about their learning disabilities who can advocate for themselves So we we're thinking that it could be because the protective mechanism of resilience counteracts the level of stress in learning disabled kids And because kids with learning disabilities and behavioral challenges face more challenges They develop better resiliency. So I tell this to parents a lot So parents will say, you know, they've got the perfect child and then they've got their kid who comes to see me with ADHD and a learning disability and I say to them, you know If we can get this child into college Yeah, that child may actually be the more resilient one and I see this all the time in my work at at The hospitals. I'm oftentimes very frequently Hiring people for research assistants Right out of college from the best colleges all around the country They're great workers. They can do a great job But what happens when the first time a parent gets mad at them on the phone because they're trying to Schedule an appointment for an assessment or they're working with a child a lot of times what I find is these great great students Crumble they don't know what to do when a supervisor says, you know The way you do that wasn't quite the way it needs to be done. They think it's it's the most Horrible thing to hear because they've never really heard that Whereas kids with these kinds of challenges if we can get them successfully to adulthood They make great employees because they know life's filled with challenges life's not easy I know that and they keep plotting on so it's it's interesting to to think about and I see it all the time in my own daily life Now I just want to mention I think I have um Maybe 10 more minutes five or 10 more minutes and I'll take some time for questions again I want to mention um at least one Sort of cutting-edge treatment program for these kids who are not as resilient or who are more treatment resistant or Who we have more difficulty reaching and I want to talk about the role of collaborative problem solving or cps and this um problem solving Kind of program is done through a program at mass general hospital called think kids And if you guys are interested in hearing more about this for those of you don't may not already know about it If you went go online and look up think kids you'll find more about this They have great information But I just want to kind of wet your appetite because I think that this is a nice sort of Framework to to think about interacting with kids on a daily basis who have these kinds of challenges So the philosophy behind collaborative problem solving is thinking about kids do well if they can Not if they want to And it is sort of an unconventional kind of way of thinking about kids is that and I know again as I have no trouble putting this into practice in in work But in my daily life sometimes it's hard as a parent to remember this And I I don't know if I mentioned this but I was a classroom teacher when I first graduated from college And I was a special ed teacher and so I know what it's like to sort of be in there day in and day out Like dealing with kids from you know eight to three And it's hard to remember that kids will do Well if they can if they know how to do well not necessarily if they want to So let me just talk for a second about this in terms of the conventional wisdom um The reason why I put this picture this drowning person is kind of think about people at the beach And there are 10 people swimming nine of them know how to swim One of them does not Who's trying the hardest to swim here? It's the person who doesn't know how to swim and so Doesn't matter how much if that child doesn't know how to swim or that person doesn't know how to swim It doesn't matter how many times I say just try harder keep trying keep going get faster They're not going to swim. They just aren't Even reinforcement isn't going to work for this person It's like swim and then I'll give you a treat after you learn after you do this It's not going to work for them neither is punishment. They just don't know how to do it So the kids that I've been talking about are kids like this They're the one in 10 or two in 10 who don't know how to swim And so this kind of collaborative problem-solving sort of turns conventional wisdom Um on its head a little bit that challenging kids those most challenging kids that we see lack skill not will And again kind of thinking about those executive function skills Oftentimes those are the underlying skills that we're seeing that are problematic for these kids problems with flexibility Adaptability frustration tolerance and problem solving skills So kids who can't figure out a solution to a problem are going to look like they're having behavior problems Not necessarily because they're just wanting to act out because they don't know what exactly to do The other thing we need to think about just like building resiliency These kinds of skills can be taught and developed So there are kids who just are not as good at executive functioning as others, but we can teach these skills It's a long process and I think that's one of the hardest things for parents to remember Is that these are not skills that are taught this year? They're not going to be taught in third grade and they're not going to be taught in eighth grade But there's skills that we need to develop over the course of the lifespan really but definitely throughout childhood and young adulthood So the research that is looked at these challenging behaviors has shown that there are five different areas that are problematic for these kinds of most challenging kids Again looking across disorders Um, and there are five different areas. One is the executive function skills that I've mentioned Language processing skills so kids who just don't process language as well who just have language disorders have More behave this kind of disruptive behavior disorders problems with emotion regulation Problems with cognitive flexibility and problems with social thinking so we kind of pulled out when we looked at the research Work when we're looking at cognitive flexibility. That was such a big area I know it's also considered part of executive function skills But it was such a big area That we actually pulled that out in terms of looking at the at the research on these skills deficits These are the kids when you kind of think about where they have a big problem It's when going from one activity to the next or even within a problem on a worksheet going from one kind of problem to the next That's a that flexibility is really tough So these kinds of skills and the think kids model Looks at the fact that these skills are best taught naturalistically in a relational context So these kinds of skills aren't something that necessarily lend themselves to of course in executive functioning You know, there's a place for that too, but not necessarily these are something that needs to happen in the here and now So again, let me just i'm just going to whet your appetite for this But basically this kind of unconventional thinking Looks at three different kinds of Plans or assumes that they're assumes that there are three different kinds of plans So anytime that a child is Giving you some kind of a problem There's three there are basically only three things you can do one is you can impose your your will on them You're going to do it. You're going to do it now. I don't care what you say um Sometimes that doesn't work, but that's that's an option The other option is to solve the problem Collaboratively and I'll talk about that a little bit more and the other thing to do is to drop it That's really those are really your only three choices Sometimes dropping it is the right thing to do. Sometimes it's sort of like, okay. This is a battle I'm not going to choose to fight right now at least not right now but um The solving the problem Collaboratively is the area that can actually help kids learn these kinds of skills that they're deficient in So plan a again imposing your will what are the goals that you achieve for that? For example, well, you get your expectations meet met Maybe maybe not. I mean sometimes imposing your will you can not even get that met But but let's just say it worked that you get your expectations met Plan c dropping it you reduce the challenging behavior So the child is having a tantrum or they're refusing to do something you say, okay, you don't you don't have to do it All right problem solved, but not really because they didn't actually Give you what you were asking them to do this plan b this idea about collaboratively problem solving Hits all of these areas you get your expectations met You're reducing the challenging behavior. You're also helping them solve problems build relationships build skills So what does this look like this plan b? And again, I'm I apologize for kind of rushing through this But it but it kind of gives you a way of thinking about this So plan b involves three different things empathizing with a child Sharing your concerns and collaborating. So for example, let's say a child is having trouble getting along on the playground And is being perhaps even somewhat of a bully on the playground What what you'd start with is to empathize actually with their concerns empathize with Okay, I see you're and I don't mean like saying like it's fine I understand why you're doing this but empathizing in a way to say I see you're having trouble with Billy on the playground now. You don't seem to have trouble with him in math class What is it about the playground that seems to be causing you guys to have this conflict? Or seems to be making you act like this So you're and then you're going to clarify what the child's concern is. How do they see the problem? You're going to share your concerns and then you're going to brainstorm with the child About possible solutions So and it's this kind of plan is much more about Thinking through a problem as opposed to feeling the problem So for we oftentimes spend a lot of time talking to kids Well, how did it make you feel when you did that or how did it make you feel when? So and so did this or how does it make you feel when you don't get your homework done? That's important, but that's not actually helping them solve the problem I mean it's important to know how you feel about different things But what we're trying to do with this kind of a problem solving plan Is to actually get them to generate solutions to get them thinking about what the solutions potential solutions are And kids may come up with good solutions and they may not And it's your job in this kind of Problem-solving approach to help them evaluate. Well, what would happen if you did this? So let's say you tried this solution. What would happen? Now What's really interesting is using this kind of approach is found to be very very effective in a lot of different areas So my colleagues at at mass general Have done a number of different studies looking at inpatient outpatient residential Juveniles attention and school Settings and what we found is that for example in inpatient unit units Using this kind of a problem-solving approach that kind of addresses the child's executive function skills and underlying problems with language and those sorts of things that it reduced the number and duration of restrictive interventions decreases restraints seclusions short holds And and I should say too that these This kind of study was done really giving a lot of information to the people working in that inpatient unit But with a lot of training in this kind of problem-solving approach They found that it's quite effective even effective in staff turnover. So it it not only helps the kids It makes for happier employees because they can see that what they're doing is actually working In outpatient settings, it's associated with fewer disruptive behaviors and kids with adhd Lower parent stress and higher parent-child relationships in residential settings it's Very similar to inpatient settings more restrictive inner fewer restrictive interventions less aggression better participation in community Activities and same thing in juvenile detention facilities like even in in jails they've studied this kind of approach to problem-solving more I should say fewer staff injuries fewer restrictive interventions and in schools it's associated with lower teacher stress fewer discipline referrals and again fewer of those kind of restrictive interventions So let me just kind of summarize here, and then I'll I think I'm on target for the okay, so I have some time for questions So let me just kind of pull all this together and looking ahead at where we need to start thinking about kids And where the research is going in kids is we need to look at each one of these kids very Individually and look at how each one of these vulnerabilities and each one of these risks factors Contribute to those kind of behavior problems that are most problematic for us on a day-to-day basis So in terms of cognitive vulnerabilities, we need to look at what is this child's language or communication skills What about their cognitive rigidity? What role does that play? What about their executive function skills? Again kind of thinking about that most of the kids we see Over half of the kids that we see tend to have more than one problem area It's not just we're not just looking at cognitive vulnerabilities, but also thinking more broadly What kind of emotional or risk factors do they have? Are they depressed? Are they anxious? What's their level of emotional insight? How does that play into this? How does that play into helping them strategize about their own kinds of behaviors? And then also looking more broadly. What are the ecological the contextual factors that play into this? Their academic or school challenges again all of these things interrelate Their family and peer stressors. What kind of life events have they had? What kind of access to treatment do they have now? We already know Access to treatment is a tough tough thing. It's it's The same in massachusetts. We have the highest rates of psychologists and psychiatrists And it's just as bad as what you had said is here. It's so hard to get kids treatment So we have to kind of take that into account too. What's the access for a child's treatment? And then lastly Oops, I think Oh, I actually am missing a slide but anyway lastly We also need to think about what the role of resilience plays into this and how we can actually make kids more resilient in order to Treat and to help them interact in the world despite all of these kinds of cognitive vulnerabilities And these risk factors both emotionally and contextually So I'd like to just end there And we'd be happy to take any questions. I think that what um You'd need to do is to go to one of the mics if you feel Comfortable enough doing that Good morning. Hi So I have an ill-formed question for you. Um, do you know of john righty the psychiatrist? Yes So he talks about the impact of fitness Things like activity nutrition and so in your analogy or metaphor about the car engine I was thinking they're not all equal. That's a good point. Yeah Some have a lot of gunk and they don't they're not as efficient and yes all of that So i'm wondering if you could just Touch on that briefly in terms both of in the moment like today how a kid is doing this morning Who you know, yes has difficulties with those and then also just Developmentally, oh, that's a great great question. So we know well first of all, let me talk about in the day and one of the things and I I'm glad you brought that up because there are a million things I could bring up But that the would I always tell parents because they'll say well, what's what's the you know, should I Change my child's diet. What about sugar? What and I always tell them We always feel better when we eat better when we're well nourished when we're well rested So overall That is a very important factor Overall, we know that Exercise overall is associated with lower rates of depression in both kids and in adults In fact in some studies exercise is almost as good as antidepressants So exercise is an important component of this that I Didn't mention but I'm glad you did the other thing in terms of and I didn't have time to talk as much I'm going to talk in the breakout session a little bit more what to do with kids with kind of the slow cognitive tempo But one of the things that we know Helps these kinds of kids is frequent breaks throughout the day So exercise is good overall in development Associated again with lower risks of depression and anxiety But also within the school day within the day that one of the best things we can do to rev up somebody's engine Is to give them a chance to kind of rev it up So that means more frequent recess periods more frequent times for them to actually charge their batteries So when you think about it when we're kind of sluggish anyway, what helps us kind of get moving is to get moving And what has happened over the last whenever years? You know, we've cut out recess We have cut out the ability for kids to move around as much because we have lots of Requirements and lots of things that we have to do within the classroom setting Which may actually be a reason why we're seeing more of these kids over time Is that this tends to be a bigger problem because they don't have time to kind of rev up that engine? Does that make sense? any other questions And and one of the things That i'm seeing is a slower processing speed when they're anxious, but then when they're not anxious They're not having a slower processing speed So i was wondering if it's that slower processing speed overall or if stuff is getting caught in the emotion region And they're not even getting to the prefrontal cortex to do the decision making That's a really good question. So kids with anxiety What what I tend to think of Them in in this context of slow processing speed is that it's a bi-directional kind of thing Most of the kids that I find with anxiety disorders who have that tendency to slow down when the load kind of gets too much that You know too much for them to process making them anxious is they already have a vulnerability to slow processing speed to begin with So when you look at their cognitive profile, they tend to show They may even have sort of like average processing speed, but maybe brighter than average kind of kids But when they get anxious that vulnerability tends to slow them down And so what happens is when any of us get anxious, what do we do? We kind of freeze a little bit. We kind of slow down I mean there's that's a normal response because when we get anxious what we want to like look at the situation We want to take time to make sure okay Why am I anxious? You know our brain just kind of goes into that mode So kids who have anxiety disorders who are already vulnerable in that area They tend to not just freeze but tend to get completely stuck and to Really slow down and I do find that those are the kinds of kids who are even more puzzling to treaters and to teachers because they're like they were fine in this last situation and now They're not even moving. I don't even understand why this happens One other thing that that kind of reminds me of is that sometimes even kids without anxiety tend to have these sorts of peaks and valleys and a lot of times it has to do with the task itself And this is particularly true for kids with anxiety. That means and what I'm Meaning to say is that if they know how to do the task sometimes they'll just plunge and then do it really well So I'll hear from parents like, you know the math homework on monday They came home and they did it right away and then tuesday and wednesday They didn't get it done. It took us four hours to get through a homework worksheet that should have taken us 20 minutes Very often it's because they knew how to do the homework again using the analogy of the drowning person They knew how to do the homework on monday. They came in and did it And they didn't know what to do So that those kinds of issues are even more difficult for kids who are anxious because they don't know how to do it That makes them anxious. It slows them down. They get more anxious and it becomes this kind of circle What what impact does trauma have on on learning disabled or or behavior challenges? That's a really good question and in terms of looking at some of these executive function issues We don't have a lot of great data particularly where it relates to some of the things I was talking about We do know though in general trauma just affects all areas of functioning and it's It's complicated because some of the research on resiliency shows that Sometimes kids. Oh, I'm out of time. All right. I'll finish this question So this will be the last question We don't really know that Trauma necessarily affects cognition or executive functions We do know however that it can disrupt kids who are already vulnerable in those areas So again, kind of like what I was talking about with anxiety. You're already vulnerable You already don't have great executive function skills Then you have this trauma the ability that you had to kind of interact with the environment is disrupted So kids who are come in with great kinds of again executive function skills great language skills less of A chance that they're going to be disrupted by a traumatic experience kids who are already vulnerable Much greater chance that that is something that's going to occur In terms of some of the things that I was talking about like processing speed We don't really know although it just makes sense that it would affect them I mean, it's something that I think we need to study and look at because I think those are some of our most vulnerable kids And if you're raising an anxious environment Just you kind of think that your normal way of interacting with the environment would be to slow down Because you're you're always concerned about what's going on. So it would make sense Okay, I'll stop right there