Ep. 109: Dr. Raun Melmed – A Prescription by Description

Sucheta Kamath: Welcome back to Full PreFrontal. I’m here with Todd. Hello, Todd, how are you?

Producer: I’m doing great, Sucheta. I had a pleasure of chatting a bit with our guest before we went on here. It seems like a wonderful fellow, I’m excited to dive in.

Sucheta: Yes, I am too, and just for those listeners who already know my background, this may not come as a surprise, but working with children with various diagnosed disabilities, it has almost piqued my interest to those who are not diagnosed, and one of the things culturally that we see a lot of references made to characters and personalities who have these peculiar behaviors and we always wonder particularly people like me in the field, I wonder if something has been undiagnosed? Take the example of Dennis the Menace, you remember the cartoon from, I guess, the 20s or 30s, an old cartoon, right?

Producer: Yeah, it’s an old cartoon, yes.

Sucheta: It’s an old cartoon, and if you really carefully study, as I was getting ready to talk to our guest today, I was reviewing – there was some site, I came across 87 cartoons and every single cartoon was talking about this misbehaving child, a little bit on the edge, a little bit challenging the authorities, a little bit challenging the social norms, and it’s so interesting because we look at that with amusement, but I was just thinking about the plight of the parents as well as the neighbor who’s constantly trying to have to deal with Dennis that it can be a challenge. So, very grateful for the way our field has progressed and now we know so much more, but today, we have a very special guest who is going to connect not just the issues about attention and dysregulation but also the social emotional behaviors of children, and we’re going to dive deep into the overlap, so it’s a great pleasure that I get to invite Dr. Raun Melmed. He is a developmental and behavioral pediatrician. He also serves as a director of the Melamed Center in Scottsdale Arizona. He’s also a cofounder and a medical director of the Southwest Autism Research and Resource Center in Phoenix. He is an associate professor of pediatrics at the University of Arizona and on-faculty at Arizona State University. A very, very busy man but you will be surprised at your curiosity will be piqued because some of the things that he does with his creativity, so first, Dr. Melamed is an investigator of novel therapeutic agents in the treatment of autism, Fragile X, and Angelman’s disorder, and ADHD, and collaborative studies of tools used in early diagnoses of developmental disorders, but most interestingly, in addition to offering many books such as Autism: Early Intervention, he also is an author of ST4 Mindfulness Books for Kids series, and he has written these very, very cute book, very informative, very useful called Marvin’s Monster Diary, Timmy’s Monster Diary, Harriet’s Monster Diary, but talking about different experiences. So, it’s a great honor and privilege to have Dr. Melamed.

Welcome, Raun, welcome to the podcast.

Dr. Raun Melmed: Thank you for having me, it’s nice to be here. I hope everybody is feeling well and healthy, and strong.

Sucheta: I really hope so. So, this podcast is about executive function which involves intentional focus, goal assessment, planning, adaptive flexibility, and relationship management. How would you describe your own executive functioning skills and how they influence your schooling, your work, and your interpersonal skills?

Dr. Melmed: Well, when I was a young kid, I was the type of child I think a lot of people would’ve called Dennis the Menace.

Sucheta: Really?

Dr. Melmed: Absolutely. I had the best of intentions but somehow, my intentions never actualized. I thought I was an excellent student and a very well-behaved young man and I always thought that I wouldn’t do anything other than want to please everybody around me, but that isn’t exactly how it happened. That resonated with me many years later when I was studying ADHD. It was back in the early 80s and people started talking about, is it an attention deficit? Is there a lack of attention? People always asked that because mothers always would say, “My child could stay focused for hours on something of their own choice,” on screen time, certainly, so where’s the attentional lack? One of my mentors said, maybe it’s not an attention deficit disorder, it’s an intention deficit disorder.

Sucheta: Totally.

Dr. Melmed: So, the fact is, I think every single child wants to please. When I hear principals and teachers, and even parents say, “This child really doesn’t care. This child really is trying to cause trouble, they are really choosing to fail,” and I think uh-uh-uh, I’ve never ever met a child who chooses to fail. I’ve met many children who choose to misbehave when they are failing rather than being called out as being a dummy or something. They might prefer to do something stupid so their teachers’ concerns and the children in the classroom’s concern is deflected, and people laugh at the naughty kids, but that’s not necessarily what they are setting out to do.

So, as far as I was concerned growing up, I understood the difficulties that some people had in getting what they intend to achieve.

Sucheta: You answered my next question which was about this, as a developmental pediatrician, what drew you to the children with ADHD and ASD, so I completely see this compassionate outlook towards the children that you are seeing and your own developmental trajectory.

As we get ready to dive deep, was wondering if you might take a minute to help our listeners understand from the DSM or your point of view as an expert, how do we define ADHD and ASD, the Autism Spectrum Disorder and Attention Deficit and Hyperactivity Disorder?

Dr. Melmed: Okay, let’s talk with autism. There have always been three major concerns with individuals with autism area there are children with autism who have significant social challenges, they have difficulties with interacting with others and making friends. Other children have difficulties with behavior; they have very restricted and repetitive behaviors and they have an insistence upon saying, and the third group of children have difficulties with communication. So, we had that tripod which we used to base the diagnosis in the past of social, behavioral, and communication concerns. With the advent of the DSM 5, the Diagnostic and Statistical Manual of Mental Disorders 5, that changed and instead of having three different aspects of concern, we now understood that there were really just two aspects, that we clumped social and communication challenges together and we speak of children as having social communication deficits and then we speak of children has having behavioral challenges, and this specific criteria which an individual has to meet in order to show that they truly have a social communication concern and if they also have the behavioral concern of the type that I just already mentioned, and they have those both together and they are suffering, suffering as a consequence of having those challenges, in other words, there’s dysfunction present, then they have the diagnosis of autism spectrum disorder.

Sucheta: I really liked this last part that you are emphasizing, that disruption of quality of life because I think sometimes, in spite of having these two elements present, it may not impact the child’s life goals based on what context the child’s growing up, right?

Dr. Melmed: Absolutely, so the children have to have challenges with learning or they have to have challenges communicating and interacting with their friends and their parents. Later on in life, adults have to have difficulties in figuring out how to have relationships with others, how to find a boyfriend or girlfriend, how to maintain a marriage, how to maintain a job, how to be economically self-sufficient, how to be motivated in order to get out there, how to basically navigate all the different aspects of one’s life that one has to do to be successful person, and if you are not successful, and if you are failing as a consequence of having those disorders, then we speak about you having significant impairment. Sometimes, [inaudible] impairment, and we get onto ADHD, the situation is very similar.

Sucheta: One more question about this issue between ASD, the autism spectrum disorder, and PS am now getting rid of the Asperger’s as a diagnosable disorder, what do you think about this change not necessarily picking up on some of the children and adults with settler problems that don’t meet the criteria?

Dr. Melmed: Well, that’s always been a major concern. It turns out, however, that clinicians, psychiatrists, developmental pediatricians, psychologists always have had a pretty easy job being able to distinguish between those typical in terms of their development as a child or as adults and who is not. When the individuals were not typical, when they were atypical, there was an extraordinary amount of disagreement between different clinicians as to whether the child or the adult had Asperger’s disorder or high functioning autistic disorder, or pervasive developmental disorder NOS. There was a lot of confusion. One clinician who described a particular individual as having autistic disorder NOS, the next one would have Asperger disorder, others would call it high functioning, so it appeared that because of that confusion, it was felt that it would be better to lump them all together under autism spectrum disorder which by the way, I don’t think it’s an ideal name at all because it implies that individuals are simply on the spectrum, but the other aspects of the child, what the DSM 5 did for autism was instead of dividing children into mild, moderate, severe, profound autism spectrum disorder, they chose instead maybe a more pragmatic way to go which is to look at the amount of services, the amount of need, the amount of support that that individual would have, so we talk about level I and level II, and level III.

Level I would be a person who only requires minimal support. Level II extensive support, and level III, very expensive support, and there are some guidelines as to how to do that. There are definite concerns that a more subtle individual might be best, but I think in the hands of a good clinician utilizing the tools which are available to us today, one should definitely be able to recognize even the most subtle, in people with the most subtle difficulties and figure out whether they actually meet the criteria or not. I see a lot of adults in that who are having challenges in their marriages and the marriage counselors often, astute ones, might prefer to them a very successful adult who seems to be doing very well in many capacities except in terms of their social communication and their intimacy with their spouse, and in that kind of subtle situation, using the tools available to us today, we can still pick up whether an individual who is a high functioning as that as ASD.

Sucheta: Thank you for taking the time to really explain this because one of the pushbacks in the community that I noticed is mainly for parents and individuals because there is associated with the autism spectrum disorder, being something to be embarrassed about that somehow, they have a feeling that Asperger’s is a less judgmental label, but I appreciate what you’re saying. It’s just, I think, as you mentioned, it’s not the best label to begin with but this is what we have and it’s not really indicative of there is no future or there is the opportunity for one to change themselves.

So, are there any connections between autism and ADHD? As families bring their children for wellness checkups or issues as child may not be meeting the developmental milestones, when do you get concerned as a pediatrician and what is the youngest age of these issues can be diagnosed?

Dr. Melmed: The American Academy of Pediatrics has recommended that autism-specific screening takes place between 18 and 24 months. There are specific tools, one of them is called the MCHAT which pediatricians in their general offices are strongly encouraged to utilize and to screen every single child walking through the door. If a parent already has the concern about a child or if for that matter the pediatrician already has a concern about a child’s development in terms of autism or anything else, they have already failed in my eyes to screen.

Sucheta: I see.

Dr. Melmed: So, there are different levels and types of screening that we can do. A mother’s concern is always a reason to move forward and to look under the covers and to delve deeper into the situation. I felt specific screening tool is always a reason. A pediatrician who’s astute and asks appropriate developmental sounding questions to assess a child’s communication and behavior, and social interaction, if any of those are positive, to me, that only applies a failed screen and the need to go to the next level. The mothers are always right.

Sucheta: Perfect.

Dr. Melmed: The mothers are always more accepting in one’s situation.

Sucheta: Oh, wow.

Dr. Melmed: And the only situation where a parent can be wrong if they say the child is typical, especially, for example, the mother has one child with autism who is nonverbal, not using any language at all, then they have another child who is using lots of language, and the mother tells the physician, “Oh, I have no concerns at all about this other child because they are using language.” The mother’s barometer might depend on what the first child’s behavior looks like, so even though the second child might not be impaired to the same extent, they still have significant challenges and could still be having autism. That’s why when we are doing screening, the American Academy of Pediatrics has used the tool on everybody, not just those who you suspect are typical or you suspect too are normal.

Sucheta: That’s great. My personal experience has been one, even in this day and age, I’m hearing some of my family’s pediatricians advise a wait-and-see approach, particularly in the context of ADHD in some of these social inappropriateness they’re not fully sure of, and second thing is, I wonder what you think about this but because of the genetic component there, some of these parents themselves are not skilled communicators, they don’t have the best theory of mine, so their ability to understand and read between the lines or have the social interactional proficiency, that can come in their way in judging the child’s competence or recognize that there is some lack of competence. Do you experience some of this?

Dr. Melmed: Now, there is that, and that’s why the screening tools are designed to be awfully and easy to read, and readily accessible for any parent. Occasionally, some parents might require the screening questions being read to them. It’s very quick to complete, it takes a minute or two for a parent to finish to do that. It’s a quick and easy screen, it’s not foolproof by any extent – there is nothing foolproof, except when the mother is saying, “There’s something wrong with my child,” that’s the only foolproof issue. So yes, parents could obviously be in denial and they could all have difficulties in being aware of the challenges at hand, that’s why we have to have good screening materials available in English, in Spanish, and in every language that might be utilized in any specific community, because we know that minorities’ diagnosis time period often lags behind individuals who have come from the higher social economic circumstances and who are of the dominant culture.

Sucheta: So, let’s think about the issue of prevalence, I guess. So, why are there so many kids with ADHD and ASD today?

Dr. Melmed: That’s a question that I think is on top of everybody’s mind. Now, the big issue is, is this a true increase or is it a perceived increase? Now, for the longest time, for example, you mentioned early on that autism had a bit of stigma attached to it, so people were reluctant to diagnose, make a diagnosis, and people were also unaware of ADHD. Our grandparents had the attitude that if the child was misbehaving, maybe you are acting inappropriately, that they may be needed a very harsh talking to or even worse and that the child would somehow miraculously snap out of it. In the DSM 1, the very first DSM, there were no childhood disorders at all, so obviously, [inaudible] an exponential increase in the number of pediatric developmental disorders being included in the DSM. From DSM 1 to DSM 2, if there were any in the DSM 2 at all, then the numbers went up by an infinity process.

Sucheta: I see.

Dr. Melmed: So, [inaudible] to go up, whether you started at 0, because for the longest time and basically in the field of child psychiatry, it was not even thought possible that children could have a mental health disorder, whether it was ADHD, depression, anxiety, autism, or anything else for that matter, so we have seen that when attitudes change in perceptions change, a lot of people have thought that maybe this is just old wine in a new bottle, there’s a new label involved. Qualities and perceptions have changed that in the DSM 1, there were no pediatric disorders at all, so obviously, there’s been a lot of increase ever since that time, but I think that more and more, we are interested in understanding children differently, we are interested in looking under the hood and figuring out what is different about the child? Are they just lazy, crazy, or stupid or dumb, or is there a reason for them having difficulties with their social interaction, with their learning, with their capacity to succeed in life? So, we have done a great service to many of the children and I think more and more, when people communicate with one another, when a child has ADHD, the reason they are like that at all for that matter in the labels such as ASD, it gives us a kind of lens to look into the child and instead of just looking at them and saying they are naughty, difficult, oppositional, mean-spirited kids, we can say, wait a second, how are they focusing? How much are they understanding about what’s going on? How are they dealing with stressful situations? Do they have a learning problem? Do the learning problems extend to how they socially understand what is expected of them? Does the learning problem extend to the difficulties they have in managing different sensory sensations around them? Do the problems arise behaviorally because the child has an extreme intolerance to a lack of schedule in their lives and difficulties with transitions and change? So, I think we have done a great service to children in looking under hood and in describing children and that is basically my orientation.

My orientation is not so much to worry about the label but to worry about the child, so when a difficult child presents, if I hear of a child who’s very difficult and they are having lots of challenges in many areas, whether the child is 2 or the child is 22, I try very hard to try and describe the child. What do they look like? How are they doing academically? How are they doing socially? How are they doing within their home and what is the structure of their family life? Is there any potential for conflict within the family? Is there any potential for any abuse within the family? How is the child making friends? How well have they achieved their developmental milestones? How well are they learning in the classroom? How well are they able to understand math and reading, and writing and arithmetic? How well are they able to basically function? And with that overall picture which I call a description of the child or the child’s individual profile, then from the description, the prescription will follow, so what I need to [inaudible] will determine what we do. It’s prescription by description, so if you’re not sure about a diagnosis, I advised the young residents, keep on describing, just like in medicine when you are not sure about a diagnosis, take a history, have an x-ray, draw a blood test, do a CAT scan. Unfortunately, we don’t have those kinds of tools but we have others. We have our insight, we have our history, we can look at different measures, we can ask for a psychological evaluation, we can look at a child from a number of different perspectives, and then eventually, what we need to do will come out. Now, in the process, the child will also have a diagnosis. Clearly, we need diagnoses as well at this point, but eventually, I think we’re not only going to be looking at the description of the child based on parameters that I had just mentioned and enunciated, but that mental health will be moving more to what is the genetic underpinnings rather than metabolic underpinnings. What are many different aspects of a child’s euro biological functioning? What makes them different one from another? And we well might be moving to a diagnostic categorization system where all of those parameters are taken into account, including of course, the family. The saddest thing about the DSM 5, it doesn’t include the family at all in the diagnostic categorization of these disorders.

Sucheta: I love that.

Dr. Melmed: So, if you [inaudible] in the future, that’s the direction we are going to in the future, but at this point, I think taking baby steps, we are wandering in the [inaudible], we call it ADHD, we call it ASD, we are not entirely sure exactly what it means, but we do know that we are serving the children and we are trying our best to look at their specific needs and to meet those needs, and that’s the purpose of what we do.

Sucheta: That’s really, really helpful. I think this is really meaningful because you are again, serving the needs of the whole child and the child is not his symptoms but the child’s behaviors are either exaggerated or underrepresented based on the contacts where they are functioning.

That brings me to this question about – do you mind diving deep into what are the common behaviors that signify autism spectrum disorder versus ADHD disorder?

Dr. Melmed: So, I did mention that what we are looking for in autism’s challenges with social communication and challenges with behaviors. With ADHD, of course, we have different kinds of symptoms that we look at. We look at children who have hyperactive impulsive symptomatology and we look at children who have inattentive symptomatology, and we try to at least divide children into those two categories knowing full well that many children have an absolute overlap. So, the kinds of concerns that I think of with ADHD are children who are, for example, distracting, so anyone listening to this podcast right now might have many other things on their mind. There’s a whole array of stimuli out there which are competing for our attention. We might be worrying about coronavirus, we might be worried about being laid off, we might be worried about our marriages, we might be worried about our children, so there are a lot of different things that we can focus upon and listening to a podcast requires a lot of auditory attentional capacity.

Sucheta: Yes.

Dr. Melmed: Everyone right now needs to distract and to filter out everything which is not relevant which is not [inaudible] to the topic of conversation. They have to leave aside and put aside all those other concerns and focus entirely on the content of my conversation, the content of what I am trying to get across. Are you doing that? If you’re not doing that, it means that I am not telling you something interesting or I am not telling you that you have not heard about before, or I am not telling you something useful that you are going to find useful for you tomorrow, so a teacher meeting me right now on the podcast or a teacher in a classroom over the Internet, if they have teleclassrooms going right now needs to make sure that their stuff is interesting and it’s fun and it’s you, and it’s keeping the attention, and most important, that it’s going to be useful.

Sucheta: So, are you saying that we all are very close to being diagnosed with ADHD simply by [inaudible] with life’s challenges of enormous responsibilities and ongoing distractions?

Dr. Melmed: I think we all have that particular symptom of distractibility. All of us are being distractible. How many of us right now, if everyone is honest on this podcast, how many of us haven’t had a spouse or a boyfriend, or a girlfriend say to them, “Are you listening to me right now? Are you focused on what I’m saying? Are you hearing how I’m feeling? I just said something pretty important. Did you actually even acknowledge that?” That’s one of the most common concerns, I think, that exists in any kind of relationship, is that the issue of distractibility. Now, just because you have distractibility, one of the symptoms of ADHD, doesn’t necessarily mean oh, boy, you have ADHD. I think that would be a great disservice to those who do have ADHD to say, well, I have attentional problems, I have distractibility, I’m sometimes impulsive, I sometimes don’t think about the consequences of my actions, and guess what, I’m fine, I’m doing well. What’s the big deal? Hey, caution, major caution, because if you hear people talking like that and they say they are fine, what does that mean?

Sucheta: That they are oblivious.

Dr. Melmed: They are being [inaudible] because you can’t be fine with ADHD. You have to have attentional challenges and distractibility problems, and [inaudible] connectivity problems and social failure, and you have to have those symptoms, certainly, the presence of those symptoms is one half of the equation, but the other half of the equation, as we discussed earlier, it has to be causing harm in your life. You have to be failing socially, academically, within the family, you have to be failing. You are not failing, you are doing fine, [inaudible] citizen, you certainly have the symptoms, but don’t say you have ADHD because you will be diminishing the suffering that people with ADHD to have, you will be telling them it’s no big deal. It’s no big deal for you, maybe, [inaudible] citizen because you don’t have those problems, but those individuals with ADHD, they are failing, they are hurting, they don’t have friends, they can’t succeed, they are coming home miserable every day, their parents yell at them, the parents are stressed out, there is enormous amounts of challenge with having a child or adults with ADHD. It’s a significant and a serious disorder. Don’t diminish it by simply saying, I have some of the symptoms, no big deal.

Sucheta: Yeah. Well, I think that as you clarify this, maybe you can also shed some light about some of the myths that are out there with people think about or talk about other peoples were particularly, their children’s – if they are a teacher, they serve a classroom full of students and some may have autism spectrum disorder or ADHD. What are some of the myths that we need to stay away from what we think about these two particular ailments?

Dr. Melmed: First of all, I think one of the biggest myths, ADHD is not a diagnosis, it’s just an excuse and it’s an excuse for kids to get accommodations or it’s an excuse for something else [inaudible] in somebody’s life, and when I hear that kind of situation, once again, my heart sinks because it diminishes the amount of challenges that these individuals have. Another big concern is that well, obviously, if you’re a bad parent and you are allowing your children to watch too much screen time, then you can have attentional problems and you are going to cause the problem. The biggest myth of all and parents and grandparents who have children with autism experience that was when parents with children with autism were told back in the 40s in the 50s and even in the 60s and 70s that it was their poor parenting that is causing autism. Really?

Sucheta: Oh, God.

Dr. Melmed: Decades before that, that myth had to be dispelled. And the other myth, I think, that we have is actually we actually can do anything about autism or that you can’t really change ADHD. We just have to accept it and deal with it, that’s how life is going to be, and I’m the strongest believer in intervention, especially early intervention and know well from experience that the earlier we start with intervention, both with kids with ADHD as well with kids with autism, the better the outcome is going to be.

Sucheta: Thank you. So, let’s get into the intervention. As we talk about intervention, can you help our listeners to tie that the commonality between ASD and ADHD is this executive dysfunction? I mean, that is that self-management, self-awareness, self-regulation, being able to respond to help that you get from others, but I don’t commonly see parents or individuals themselves receiving that because you have ADHD, you have executive dysfunction is clearly stated to them. What are your thoughts where the trend is moving nowadays? Are we using that language to describe the middle-management? Because a lot of times, people you may actually think you have ADHD, then get medicine and move on. That behavioral management, the cognitive intervention is completely left by the wayside.

Dr. Melmed: Well, I think this being a challenge because actually, you are right, we have pills and we have skills, and certainly, many children benefit from the pills that we use in ADHD, but definitively, there are skills that need to be learned that can be taught both in ADHD as well as an autism that at this point, there is not a pill on earth that can actually impact. You cannot use a pill to improve socialization, you cannot use a pill to improve many of the executive challenges that the individual with ADHD has. You actually have to work on the skills. That gets back to identifying what the specific deficits might be in individuals with autism as well as the individuals with ADHD as far as executive function is concerned? Are there numerous differences on executive functions? Now, one thing which I always like to think about is in the internalization of speech, the conversation that we have with ourselves inside our brains on an ongoing basis – even while I’m talking, I have another conversation going on inside my brain as I’m talking and anyone who’s listening has a number of different conversations going on inside their brain. They are thinking: have I heard this before? Is this making sense? Is this useful? Do I have this kind of problem? What do I need to remember in order to do to try and solve this problem? How can I hear more of this? How can I listen to less of it? We have this conversation with ourselves and if we have a coherent conversation, that’s going to go a long way in helping to plan a useful response to any kind of specific situation. If a speech pattern going on in our brain is terribly haphazard and somebody stops and says, “Well, what do you think about what you’re hearing right now in the podcast?” Our response is going to be pretty haphazard as well, and you won’t be really sure if you gained anything at all, but if you have an organized stream of thought in internalization of speech, then you’re going to be actually seeing a big picture and when somebody asks you a question about the [inaudible] that you’re reading or the page of biochemistry that you just read, you’re going to say, I’ve internalized what I’ve been reading and I can come up with a coherent response. So, that’s a great example of an executive function challenge that’s difficult with individuals with ADHD as well as with ASD. People with ASD have extreme difficulty in planning what they need to be doing in the future. They have extreme difficulty when they’re stuck on something and shifting their attention, and focusing on something different. So, if a child with autism or ASD is asked, “Johnny, give me the block,” Johnny is still so focused on the circle that he has difficulty shifting his attention from the circle to a [inaudible] block and will seemingly shut out the teacher, and there has to be baby steps utilized for Johnny to first of all say, “Johnny, are you listening to me?” and help him focus on you when you’re talking to him. “Johnny, I have a question I want to ask you.” Johnny can shake his head and you know that you’ve got his attention. “We’re going to be doing something different right now,” I’m breaking this little task down into teeny baby steps right now. “We’re going to be doing something different. I’m going to be asking you right now to touch the block,” so going from simply touch the circle, now, touch the block might require lots of training in order to get the child from one step to the other. The similar or same is true with individuals with ADHD – telling them to get dressed might be way too much and we might have to break down all the specific tasks into baby steps in order to get them to do what it is that we want to do, and we might have to use a lot of different reinforcements along the way, so there’s lots of executive functioning overlap between the two disorders. It will also relate to inhibition, to stopping yourself acting in a way that you should, when a child with autism who’s behaviorally challenged might just strike out without thinking about the consequences, they obviously have extreme disinhibition, and then when they see somebody in the supermarket line who is taking too much Purell from the shelf, they might say to their mother, “What a [inaudible] rude person, taking so much Purells from the shelf.” Now, that might be right but social norm would tell us, don’t say it right now, just whisper it to me instead of saying it out loud, or they might say a lot [inaudible] standing in line in the supermarket. So, there’s difficulties with inhibition that [inaudible] as another executive function that will impact both ADHD as well as individuals with ASD. So, that would be my birds eye view on the issue of overlapping executive function challenges.

Sucheta: Great, and I think from the interventions point of view since I’ve been working on that for 20 years, is a very beneficial skill development is in the metacognitive area, that helping children develop awareness of their awareness, awareness of their mindfulness, awareness of their baseline skills and abilities, and demands on their skills and abilities, and the gap, and one question I had with that in mind, I find that there is a teachers in good faith want to help these children to succeed and grow, and build skills, but they become heavily engaged in giving the guidance or directives, and the child is not made in charge of their own learning. How do you best see that we can make that shift happen? How can we and do we need to incorporate kids in their own treatment, and how does that like?

Dr. Melmed: Well, that’s my passion. My passion is to say that in any individual, even the most severely impaired individual who is nonverbal, if you could incorporate the individual issues the overall treatment plan, you are going to be streets ahead. There’s obviously medication and their special educations, and there’s lots of speech and occupation and physical therapy, and there is definitely a BA, applied behavioral analysis, but I think of attempting to engage the child in their own treatment has been precisely what the series of books I have written is all about. When we can get children to be mindful as opposed to mind-full, so what’s mindful? Mind-full is when your mind is just full of nonsense. There’s lots of just jabbering things going on as opposed to being present, being mindful. [Inaudible] your mind is not full of stuff, you are actually aware, there is an awareness, you are present. Present is a great world for mindfulness. You have to be present. How does a child become present? It’s a very difficult thing to do but if the child, what I call ST4, if the child can one S and four Ts, that’s my mantra, that’s the name of the series of books for kids. [inaudible] stops – S stands for Stop and the four Ts are: Take Time To Think. Now, if we ST4 and we write the letters ST4 ­like a formula, like H2O or CO2…

Sucheta: I love that.

Dr. Melmed: If you write ST4 on a sticker, then the child can have a sticker and they can take that sticker ST4 and they can stick that sticker on their proper folders, on their mirrors, in front of them with a wake-up, then put one on their hand when they wake up in the morning, they can walk around with it and when they are challenged with a different situation, they are encouraged to be present. Stop, take time to think.

Sucheta: I love that.

Dr. Melmed: The Monster Diaries series teach children different tools like ST4: stop, take time to think. One of our characters addresses attentional problems and [inaudible] learns how to manage her anger. She’s got ADHD and anger, and another child, Harriet, has ADHD and anxiety, so she uses of these ST4 techniques. Now, but the other techniques as well which I will let you know about. One of them is the little monsters in the Monster Diaries series use a camera. They take two fingers and if you can try and do this, [inaudible] these fingers, open them up like Winston Churchill would and take two-piece fingers from the other hand and crossed them so you make a box inside. Are you doing that now?

Sucheta: Oh, yeah, I’m doing it. I got it.

Dr. Melmed: Now, look through that little box, that’s your monster cam. Now, look around and [inaudible] around you, look at the books on your bookshelf, look at the lightbulb up above you, look at what the other kids are doing in the classroom, look at your mommy right now and see whether she’s cooking in the kitchen, look if she’s talking on the phone right now, whether you should interrupt her, look at the other kids who are doing their math, should you be doing math as well? Look at the other kids who are all being quiet in silence, should you be doing that? Look at your brother and sister playing with a puzzle really quietly, should you interrupt them? So, that is the monster cam or the monster camera.

Sucheta: I love it.

Dr. Melmed: So, that’s a great way of doing that and [inaudible], that’s part of the ST4 series, stop and take time to think, then you can use a camera, or you can use a thermometer to determine the level of anxiety that you are having, so draw a test tube picture on a piece of paper right now, take a piece of paper and draw a test tube and divide the test tube up into four different layers. The first layer, color yellow. The second layer of the test tube, color green. The third layer, blue. The fourth layer, bright red. Are you feeling stressed right now? Okay, Sucheta, which color are you feeling stressed? Up to which color are you going? Are you red or are you yellow right now? Or are you green or blue?

Sucheta: I love that. Well, I am yellow because I am with a friend and I have no stress.

Dr. Melmed: Well, [inaudible] where the child is stressed though, simply by color coding their level of stress, by identifying how stressful they are, and not even by doing anything else, you’ve gone a long way to helping stress management in any age and stage of a child. If you want to be more explicit, you can but they really angry stressed-out face and draw a picture of that next to the red. If you’re feeling just a little bit stressed and just a sadder face, put that next to the blue, and of course, put a sunny happy face next to the yellow, so they can be more explicit, which are you feeling right now? There are many things which Harriet in Harriet’s Monster Diary learns how to manage her anxiety, including the feel of this thermometer which she uses a lot, but then of course, there are lots of other activities like relaxation and stress reduction activities which you can use because basically, we are talking about two stages in stress management: how do you feel, identify the feeling with these colors or these pictures, that is the first step, and there are only two steps. The second step is okay, what can you do about it? If you identify the level of stress and come up with a coping strategy, and of course, there are many around and there are some great online activities. I have just seen that Ninja Focus is an example of like a stress management tool for children, Ninja Focus, you can download that for free and of course, you can read these ST4 series which you can get as well, and they have lots of activities which children can use in order to take charge of themselves, be part of the solution, feel that they are integral to the overall treatment of their challenges.

Sucheta: I love it. What’s so interesting and amazing is that you are not only a diagnosed vision but you are an interventionist; you’re giving parents help, you are giving children agency, and particularly, your book series is so helpful. I was going to ask you, how did you become a writer of children’s books? I just see your passion translated into this series of books. It’s really incredible.

Dr. Melmed: Basically, I was using all these techniques – I have used them in my practice forever and I thought, wouldn’t it be nice to put it in a series of like the ST4 Mindfulness series, so it could reach lots of children? I know the children who have seen my practice on a day-to-day basis, they love these tools, they love learning about it, and they also love hearing that there are other children who have similar difficulties and when they see heroes like the monsters in the Monster Diary because they are all superheroes utilizing these tools and solving their own problems, the children do a great job, and they enjoyed it, and it’s been wonderful. I have really enjoyed it and it’s been able to reach far more children than I ever dreamed I could.

Sucheta: Oh, well, I’m happy you put this into writing and put it out in front of the children. Thank you so much for these incredible ideas, but most importantly, helping is really organize our thoughts around the similarities, overlapping patterns and behaviors, and presentations in children with autism spectrum and attention deficit hyperactive disorder, and then tying it back to executive function challenges that are pervasive that sometimes may be invisible to the naked eye, so to speak. Lastly, offering something very concrete, specific, and totally doable in everyday life. So, thank you very much for your time and your hard work in helping every child. I very much appreciate that.

Dr. Melmed: Thank you, it’s been a pleasure.

Producer: All right, well, I can say that my stress level is at red because I hate to see this conversation end. What a great chat. All right, that’s all the time we have for today. If you know of someone who might benefit from listening to today’s podcast, a teacher perhaps, principal, coach, parent, or student, we would be most grateful if you would kindly forward it to them.

So, on behalf of your host Sucheta Kamath, today’s guest, Dr. Raun Melmed, and all of us at the excuse, thanks for listening and we look forward to seeing you again next week on Full PreFrontal.