Full PreFrontal

Ep. 108: Margaret Sibley, Ph.D. – A Field Guide to Engaging the Inner Rebel

April 24, 2020 Margaret Sibley, Ph.D. Season 1 Episode 108
Full PreFrontal
Ep. 108: Margaret Sibley, Ph.D. – A Field Guide to Engaging the Inner Rebel
Full PreFrontal
Ep. 108: Margaret Sibley, Ph.D. – A Field Guide to Engaging the Inner Rebel
Apr 24, 2020 Season 1 Episode 108
Margaret Sibley, Ph.D.

The struggles of kids with ADHD are unmistakably unique and undoubtedly complex, but their lack of mental readiness to accept help is equally confusing. Nothing is more discouraging or draining for educators and parents than kids who resist direction instead of leaning into the help they receive. Since disrupted executive function in ADHD kids often interferes with their ability to accomplish tasks and manage personal success, their transition into young adulthood does not resemble that of the pre-teens and teens without ADHD and hence they need the help to work for them.

On this episode, Margaret Sibley, an Associate Professor of Psychiatry & Behavioral Sciences and a licensed clinical psychologist, shares her insights into the motivational and executive function difficulties in adolescents and young adults with ADHD. She discusses how best to develop both the skills to manage ADHD symptoms and the skills essential for transitioning into young adulthood.

About Professor Margaret Sibley, Ph.D.
Margaret Sibley is a licensed clinical psychologist and researcher on executive function and motivation difficulties in adolescents and young adults. She directs programs of research in Miami (Florida International University) and Seattle (Seattle Children’s Hospital). Dr. Sibley is the author of Parent-Teen Therapy for Executive Function Deficits and ADHD: Building Skills and Motivation. She has published over 75 scientific articles on ADHD and related disorders. Her research has been funded by the National Institute of Mental Health, U.S. Department of Education, and the Klingenstein Third Generation Foundation. Dr. Sibley is a member of the Motivational Interviewing Network of Trainers (MINT) and an expert on parent-teen collaborative and peer-delivered treatments for adolescents with ADHD.



Support the show (https://mailchi.mp/7c848462e96f/full-prefrontal-sign-up)

Show Notes Transcript

The struggles of kids with ADHD are unmistakably unique and undoubtedly complex, but their lack of mental readiness to accept help is equally confusing. Nothing is more discouraging or draining for educators and parents than kids who resist direction instead of leaning into the help they receive. Since disrupted executive function in ADHD kids often interferes with their ability to accomplish tasks and manage personal success, their transition into young adulthood does not resemble that of the pre-teens and teens without ADHD and hence they need the help to work for them.

On this episode, Margaret Sibley, an Associate Professor of Psychiatry & Behavioral Sciences and a licensed clinical psychologist, shares her insights into the motivational and executive function difficulties in adolescents and young adults with ADHD. She discusses how best to develop both the skills to manage ADHD symptoms and the skills essential for transitioning into young adulthood.

About Professor Margaret Sibley, Ph.D.
Margaret Sibley is a licensed clinical psychologist and researcher on executive function and motivation difficulties in adolescents and young adults. She directs programs of research in Miami (Florida International University) and Seattle (Seattle Children’s Hospital). Dr. Sibley is the author of Parent-Teen Therapy for Executive Function Deficits and ADHD: Building Skills and Motivation. She has published over 75 scientific articles on ADHD and related disorders. Her research has been funded by the National Institute of Mental Health, U.S. Department of Education, and the Klingenstein Third Generation Foundation. Dr. Sibley is a member of the Motivational Interviewing Network of Trainers (MINT) and an expert on parent-teen collaborative and peer-delivered treatments for adolescents with ADHD.



Support the show (https://mailchi.mp/7c848462e96f/full-prefrontal-sign-up)

Producer: Alright, and welcome back to Full PreFrontal where we are exposing the mysteries of executive function. As always, I’m here with our host Sucheta Kamath.

Good morning, my friend, good to be with you. As always, I’m very much looking forward to your conversation today.

Sucheta Kamath: Same here, Todd, I’m so excited because I get to dive deep into ADHD today. So, before we talk to our guest, I was thinking about that we used to read about dysfunctional families and apply to raising children in books, but lately, movies and television shows have done a really good job capturing the complex dynamics and all that ensues having to deal with people with different challenges and personalities, I guess, and sitcoms truly have done a very good job of showcasing general dysfunction in an endearing way that becomes, of course, laughable. One particular sitcom comes to mind is called The Middle – I don’t know, have you heard of it? But there’s one particular character that always makes me laugh. His name is Axel and he’s the oldest of all the children, I guess. There are three children and one peculiar thing, if the parents ever took this kid to a psychologist, he would be diagnosed with ADHD, but the sitcom began, he was in high school, and then now, he’s in college, but one particular episode comes to mind where his mom who’s exhausted having to raise the family in dealing with these kids. She wants to watch this episode of one particular, I don’t know, show, and she sits down, plops on the sofa and she’s like, hungry, starving, she wants to see the show, she was everybody to get out of her way, and she puts her hand in between the pillows and feels there is like a bag and it looks like a bag of chips, and she’s so excited to find some snacks. He opens it but there’s hardly anything left, so she’s busy watching, she puts her hands, stuffs her mouth with the crumbs that are left over, and eventually, the middle daughter walks in and says, “Mom, what are you doing?” She says, “What I’m just eating chips and watching my show. Get away,” and so the daughter screams and says, “Mom, Axel put his toenail clips in that bag!” and she’s like, furious, she jumps off and she runs to the sink and she’s throwing up and say, “I can’t believe, why would you, Axel, do that?” and he says, “But mom, why would you eat from a bag of chips that doesn’t have chips anymore?” And anyway, this goes on and on, but this is typically what I see in my practice when a young teenager comes with ADHD, he’s very argumentative, very stubborn, difficult to deal with, but he always is amused by other people’s inability to understand the perspective that he often has which is making a big deal about nothing.

So anyways, this is what I’m looking forward to sharing with you all, the sitcom and all is great where all these hilarious situations are depicted, almost normalizing dysfunction, but what does it mean to families who are raising children who are struggling with these issues? So, that’s why it’s a great privilege and honor to welcome Margaret Sibley. She’s an associate professor of psychiatry and behavioral science at the University of Washington School of Medicine, she’s a licensed clinical psychologist and research on executive function and motivation difficulties in adolescents and young adults, she directs programs of research in Miami, Florida International University, and Seattle which is Seattle Children’s Hospital. She is also a fabulous author of a book Parenting Teen Therapy For Executive Function Deficits and Adhd: Building Skills and Motivation. I’m very excited to speak with her. She’s an incredibly well-researched and funded, and published researcher, and she has brought some very unique and specific techniques that have added value to somebody like me who is a clinician doing this work in the field. So, Maggie, welcome to the podcast.

Margaret Sibley: Thank you for inviting me.

Sucheta: So, I ask this question of all my guests, since we do talk about executive functions, self-sufficiency, and insight, do you mind taking a minute and telling us about your own executive function as you reflect back on your teen years and as you transition into becoming a full-fledged adult?

Margaret: Sure. I think there is a story that comes to mind. When I was in ninth grade, I had always been a good student throughout school, but when you get to high school, it gets harder, so when it gets harder, you have to start figuring out a strategy to do well in school. It doesn’t just automatically happen because you are sitting in class, and I remember one history class that I took in ninth grade was just requiring us to read, learn, and basically be tested on a lot of information about every historical fact that they could probably think of from Europe, from like, I don’t know, 1200s until today. It was a lot of information, the final exam, and it was the first time I really had to figure out how I was going to tackle this. I remember, I don’t even know how I figured out what I was going to do, but I remember just making flashcards of everything that was ever presented in the class, through all my notes, through all my readings, through everything we have been tested on previously and just spending like, four days holed up in my room, memorizing these flashcards, testing myself, trying to present the information to myself in different ways.

Sucheta: Wow.

Margaret: In the end, I ended up getting a super high score on the test and I think why that stands out to me, it was the first time that I realized that I actually have control over how well I would do in school. If I picked the right strategies and applied the right amount of effort, that it wasn’t just, oh, how much did I happen to remember? But like, hey, I can actually exert an influence on how well I do on something, and that sticks out to me. So, if it ever since then, I felt confident that if I had the tools and I had the interest, that there wasn’t any reason I couldn’t do some sort of academic task, and maybe that sort of feeling and lesson is something that I hope that we can help kids develop, especially kids who historically struggled in those areas.

Sucheta: Thank you for sharing that. I think it’s so interesting that, of course, this is an exemplary motivation here and a wonderful self-discovery which you took to heart, and this is a problem for many of the kids that we work with.

So, before we jump into ADHD and children with ADHD, let’s start with executive function. What is the best way to understand skills that are collectively referred to as executive function, and particularly since they impact development, learning, and education, what’s the relationship, in your opinion, that exists between these skills and raising kids to be engaged, self-directed, and efficient?

Margaret: So, as you know, because of the title of your podcast, in our prefrontal cortex in the front of our brains, we have functions going on, different brain abilities that are happening, and it turns out that in that particular part of the brain, it has a lot to do with sort of like your pilot seat control over your decision-making, it has to do with lower order executive functions which could just be do you have the ability to stop yourself from doing something that would be against meeting one of your goals? Do you have the ability to ignore distraction to allow yourself to do the best that you can do? Can you come up with a complex plan? So, we have all these sort of natural abilities in that area and some people have really strengths in that area and some people have deficits in that area, and most people have a collection of strengths and deficits in that area. So, when we are working with kids who are struggling in school and trying to understand if executive functions have anything to do with that, and part of it is trying to understand is that profile of where your strengths are and trying to capitalize and use those strengths to be able to help you overcome those deficits.

Sucheta: I really like the way you are describing that there is a lower-level executive function and higher-level executive function, and we are a collection of all of them. I also noticed that or often describe to children that your executive function skills in the morning might be far better in the evening when you haven’t eaten or have exhausting day, or you’re irritable and you’re annoyed, as well as your lack of sleep the night before can impact your ability to function well. So, I think what I’m gathering and you’re trying to tell our listeners, that these are dynamic skills and they way they potentiate can be differentiated not just individually but also a person’s own abilities might vary, correct?

Margaret: Yeah, I mean, if you’re trying to say that it can vary in one person throughout the day depending on what’s going on, and also every person’s going to have, on average, what their abilities are going to be like, so my best on one executive function might be somebody else’s low point, right? Because they just happen to have more abilities than I do in an area but throughout the day, certainly, it can vary and it varies by interest level, it varies by the demand of the task that’s being asked of you, it varies by things like you mentioned, sleep and eating, but also things like, you know, with teenagers, it varies if you smoke marijuana, it varies. A lot of different — if you’re distressed or distracted, or depressed, there’s all kinds of things that can modulate those abilities.

Sucheta: Yeah, so that brings us to our favorite population which is ADHD children and adolescents,and adults with ADHD. It certainly interferes with self-directed attention and kids’ ability to sustain their motivation, particularly when stuff is hard and boring. So, do you mind walking us through the challenges associated with motivation in people with ADHD and do these challenges show up differently during various developmental stages? What do you think about that?

Margaret: I like to use an analogy for motivation and it’s sort of like a car, right? So, in order for a car to drive well and work, there’s a lot of different things that all have to be working underneath the hood. It’s not just one thing, one engine, and motivation is a similar way, even though it’s sort of when we look at it, we think about motivation is effort a lot of times, but really, underneath motivation, a lot of different processes that have to work together in order to have a successful result. So, for example, a person with ADHD is going to struggle with motivation often for several reasons. For one, they have lower levels of intrinsic motivation which is essentially, how much do I like doing this task? And if it is an academic task, for example, people with ADHD have lower levels of intrinsic motivation for a few reasons. I mean, one of them is the dopamine response in their brain. It’s firing in an irregular way that makes something that is maybe somewhat engaging and interesting that you’re being told about in class for the average person feel completely boring for a person with ADHD because it may just not feel stimulating enough. They sometimes need higher levels of excitement or engagement to keep their attention. So intrinsic motivation, how much they enjoy something could be impacted because of the dopamine issue but it could also be impacted because after years of getting negative feedback from parents and teachers, and peers, you just sort of don’t enjoy learning because you have the belief about whether you’re good at it, whether you can have the rewards of learning come for you if you work hard at it, and that kind of brings the second piece which is what we will call self-efficacy. So, do I believe that I am capable of doing well if I tried, right? So people with ADHD, after having a lot of experiences with maybe negative failures in school, they start to develop beliefs about their abilities, and because of that, they may not even feel like there’s a point in putting forward a lot of effort, even if they want the end result because they don’t feel like they are good at something, and then we have another piece of motivation which is in extrinsic motivation, so basically, being motivated to do something because it’s going to get you some more or earn you an outcome that you’re interested in, and so people with ADHD, sometimes when they’re sitting down and talking with you, they can tell you they want to get this grades but in the moment, it’s really hard for them to summon that motivation, and I think that is where executive functions often come in with respect to effort level, so if you have poor working memory, it might be harder for you to kind of hold mind the fact that the reason I’m doing this really hard or boring home work assignment is because I want this goal, I want this external outcome, I want those high grades, I want to please my parents, so it’s kind of like a really multi-pronged issue for people with ADHD. It’s not just that their executive functions but it’s motivation and the way they interact, not having the willpower to resist the temptation to get on your phone or to watch TV when you should be doing your homework, all that plays in and they draw on different areas of the brain, so it is a complicated issue and really hard for folks to overcome.

Sucheta: Yeah, and as you’re describing, I’m just making mental notes here that I think people have a very superficial or commonsensical notion of what motivation is and people typically think that pulling yourself up by the bootstraps by somebody else yelling at you or saying it’s important will be adequate tool or a facilitating avenue to help people summon their own motivation and it never works, but if you look at the conventional wisdom or how parents and teachers handling it, often, people are either motivating children who are unmotivated through threat or through words, and none of them seem to have long-lasting effects as you would like to see in terms of building skills, right?

Margaret: Yeah. So, what I tell parents is it’s kind of like a balancing act, right? Because on the one hand, if you want people to develop self-motivation, then you have to give them opportunities to A, find out what they are interested in, B, have some experiences with failure, so that they understand the negative consequences of not working hard and trying hard in school or in extracurriculars, or socially, so they can understand that why would I want to do something, and if parents are always rescuing their kids from the consequences, then that can have an impact on the kid’s ability to learn those lessons. On the other hand, people with ADHD can get themselves into some real trouble if they make missteps, so for example, a ninth grader with ADHD who’s just not super motivated, if they fail school, they are all of a sudden putting themselves at risk for not graduating from high school which has big consequences. If a first grader isn’t doing well in school, good consequences aren’t that grave. So, it’s important that we still equip parents with the tools of being able to use external motivators with their kids, especially in times of crisis, so that if you really need to get through that last semester of high school and keep the grades up just so that they can graduate, that parents can learn how to use tools like the contract with the teams where they might say, you can only use of the car if you keep your grades up above a certain level, etc., so that those external motivations and internal can be part of the picture.

Sucheta: Yeah. I really like that you are talking about the seesaw and the balancing act comes so much from wisdom. One of the things I see, Maggie, is people do not necessarily have psych-wise attitudes. You know, a lot of times, they don’t understand human psychology, human behavior, and then they, in the moment, particularly when things are spiraling down, tend to do what feels right, and when their set punishment feels right. When somebody’s not cooperating, hefty reward seems right, and it sounds like even just to wait and allow kids to make a mistake, and then come back and do some reflection may have significantly higher value than just acting with your own impulses.

Margaret: Yeah, that’s right, that’s a parent’s executive function issue right there, is for the parents, it’s the same skill, right? Keeping in mind the big picture of what you are trying to do as a parent, what your values are, what your goals are and not allowing your emotional response to dictate your parenting choices, instead always be checking with yourself about like, how does what I’m about to do guide my bigger goals, my bigger values of how I want to raise my child? And that’s really hard for people because those emotions do run strong when you care about someone and you really want them to be successful, and you’re watching them see what seems like such an easy thing to correct and yet the person is not performing how you want them to be.

Sucheta: Let’s talk about executive dysfunction as a primary symptom of ADHD, and ADHD at the time of transition into young adulthood looks quite different than those who are younger as children or preteens. I would love to hear your experience in this particular area and how has that informed your research design as well as research questions that you have asked as you have studied this?

Margaret: So, I think there’s few factors that influence what executive function looks like in different parts of development. For one, it’s the biological maturational process inside of someone, right? So, as people get older and their brain develops, and lessons in particular, the brain goes through a process of pruning where it keeps the brain cells it needs and it essentially gets rid of the connections that it doesn’t need because they are not being used, but in a way, that’s a good thing because it creates more density and strength in the areas where we are using it and allows us to really get good at the things that we are practicing and using everyday. That process culminates not until young adulthood when we would finally see that the brain kind of settles into what it’s going to become and gains its full abilities. So, as somebody is transitioning out of the supportive and structured format of high school and into a much more wide open young adulthood which is what our society typically brings for people, you see that their executive functions still have not matured to the full adult level. So, suddenly, there’s a mismatch between the demand and the expectations for an individual and what they are capable of. You see this mismatch really start, I would say, in adolescence.

Sucheta: Absolutely.

Margaret: But I think it’s prominent at the transition to young adulthood because the expectation that we have a society for a 19-year-old are that they find something that they are interested in that they either work on as a job and be independent with that or that they enroll in higher education which is complicated and challenging for people, so we are suddenly expecting them to sort of take on and be self-sufficient, and in some cultures, live outside of your family’s home, and in others, start contributing to your family’s income. So, all of these things where you are suddenly expected to act like an adult yet you don’t fully have all the brain abilities that somebody over 25 has yet can make it a really challenging time for folks, and so there is sort of a need in the community of people treating folks with ADHD to really be thinking about how do we step by step allow people to learn and develop skills, and discover themselves so they know what they are interested in during that time, and sort of play the long game, that our goal isn’t to make you optimally perform today, but our goal is that by the time you’re 24, 25, out of college, looking for your first career job, that you feel prepared and you know who you are and what you want to accomplish, and what skills and steps you need to be able to do that.

Sucheta: Yeah, I feel like in this particular area of life, I feel there is no rehearsal. It’s all on, you are fully on all the time. There is no opportunity to exercise or put your skills to test, or do a dry run. If you mess up, you’re out, and I’m so shocked and surprised how some people manage to be very successful in their teen years and young adulthood. So, you have a very compassionate view of this. What was the second factor you were talking about, the mismatch between what’s expected and the skills that are present?

Margaret: That’s right, the expectations and the developmental abilities.

Sucheta: Got it. So, with that in mind, I think the psychologists, speech language pathologists, educational experts, particularly those who work with disability have a much more discerning eye, but these kinds of pieces of information has not infiltrated the common realm of education the way teaching and learning happens. Why do you think such disconnect exists, in your opinion?

Margaret: I think the main issue is just that it’s good information about psychology is not something that we run into in everyday life. For one, there’s a lot of bad information about psychology out there that’s easy for people to get their hands on over the Internet, and so there can be a lot of conflicting opinions about what’s the best way to understand and help someone with ADHD or other difficulties like that? And people who are professionals have more training in that, so they have the lens to sort of not only understand some of these more complex pieces of the puzzle but also when they see a kid with ADHD struggling, to kind of understand where that’s coming from.

Sucheta: Yeah. Since Internet has become accessible to everybody, people are googling symptoms, and then they are seeing horrific range of disabilities, disorders, or diagnoses they can have. A funny story happened over the weekend. I met a family and they have twins who are 12. I’m very fond of these kids, and so I was talking to the parents and how they are adjusting, and how is middle school and blah, blah, blah? And then the father says to me that one of the sons has some skin condition and he’s really riddled by it, and they are concerned about it, and so I quickly asked, because we share a very common friend who’s a dermatologist and a very close friend of ours and she’s phenomenal, and the family said, “Oh, no, we googled it and we are applying some lotion to it,” and I said, “It’s preteen, such stressful time, and why wouldn’t you consult somebody who actually is educated and has the knowledge?” It literally is a matter of text that people feel almost like a proxy of having this kind of access is what makes them feel that they have the skills. It was very interesting to me.

Margaret: Oh, another issue, I think, is the term “attention deficit hyperactivity disorder” is pretty classic. It’s rooted in our understanding of disorder from 30 or 40 years ago, and so even when you look at the symptoms in the diagnostic and statistical manual that people are supposed to use to diagnose ADHD, they describe things that are not necessarily found in like what we are talking about right now even though they are the same things, and a part of that is that the criteria for ADHD that were developed for children, part of it is that we didn’t understand as much about the brain back when they were written, and so I think something you said earlier, executive functioning deficits are probably the core feature of ADHD in a lot of ways, and as well as motivation difficulties, and so I’m not sure what the future is going to bring in terms of whether we update the lexicon of this disorder for our modern understanding of it, but I think that that is another thing that gets in the way, is  just how we talk about ADHD and what society thinks up when they hear that term.

Sucheta: Yeah, so I’m so glad that you wrote the book Parenting Teen Therapy for Executive Function Deficits and ADHD: Building Skills and Motivation. Tell us what’s the most critical message you have in there that one must not ignore.

Margaret: I think the most critical message is to take it slow in trying to help your kids and to not expect them to get to where you are hoping they will be overnight. I think it’s important to remember that what you want when you’re working with a teenager is for them to be ready to be an adult when they are 18 or 19, not for them to be perfect tomorrow. So, we are slowly putting in place the things that we know will increase the likelihood that a teenager will be successful long-term, and sometimes, we are going to do things as a parent, as as a teen oday that takes effort, and we won’t see the rewards or the positive impacts from those things until three or four years from now, but we still do them anyways because we know they are the things that when you put certain strategies in place or you parent a certain way, or you set up the home in a certain way, that the researcher shows that those things pay off long-term.

Sucheta: And that’s such a powerful message. I think it’s, again, compassionate and encouraging for people to allow the wiring of the brain, allow the bigger picture of personal agency to kind of kick in, and also, through these difficulties, when the kids are a little bit more rigid and stop, and they want things to be entertaining, amazing, fabulous, to be involved im. If they look boring, annoying, or tedious, they don’t want anything to do with it. If you look at life, it’s a mixture of all these good, bad, and ugly daily activities that we have to still engage in. I tell kids all the time that you can’t really dream of going to LA or sunny California without actually standing in line and going through a boring process which is very boring, and then sitting on a plane and just not moving which is boring, but once you come to LA, then you can do whatever you want, so that requires a lot of patience.

So, let’s talk about motivational strategies that work. What are some of the parenting strategies that are likely to be most effective with unmotivated and disengaged teenagers with ADHD?

Margaret: So, I think the biggest message here is that you shouldn’t fight with what your kids care about and try to convince them that what you care about is more important. That never works. Instead, what you need to do is get to know your kid and find out what they are interested in and what they do care about, what their goals are even if you think the goals are ridiculous, and then try to help your kids see the connections between the things they want in life and the things that we know are positive and healthy for them, and even though you’re not going to find perfection, if you can just sort of, as a parent, pick one or two things that are important to you and that’s your most important parenting goals and values for your child, and focus on what you can do to support your kids for moving towards those things and let the rest of the little things go, that’s where you’re going to have a lot more of a manageable and less stressful time at home. So, on one hand, we’re trying to slowly over time build those interests and build those positive choices, and on the other hand, you still have those moments where you need to change bad behavior right now, and something unacceptable is going on and you know as a parent, like what are my things that are just the deal breakers for me? Whether it’s drinking or whether it’s acting in a certain disrespectful way to others or being aggressive in the home or lying, those deal breakers, and then having really clear expectations around behavior with respect to those things and also having clear consequences that you’ve agreed on and set up with the teen ahead of the time and not as a reaction to when it happens, so that it’s really systematic and easy when a teen decides to break a rule, that’s their choice, they knew what the consequences were going to be, and if they break the rule, you apply the consequences, you don’t need to get into a lecture, you don’t need to make them feel bad, that’s their choice about what in the moment they think is more important, getting the consequences or whatever it was that made the behavior appealing to them in the first place, so it takes the emotion out of it and it just sort of makes things a lot more calmer for people at home to take that kind of proactive approach.

Sucheta: Fantastic. Do you mind sharing with some practice ways this may unfold in a house and how would that be different from a classroom setting where the teacher might also deploy some of these motivational strategies?

Margaret: Sure. So, I think for one, clear expectations from the parents for teen behavior begins with a conversation, right? So, it’s not about listing 20 things that you expect out of your child but it’s about coming up with a couple of things that are important and sharing those expectations with your child, and if those expectations have historically not been met, then one of the tools that we often use when a teen is ambivalent about whatever the parents’ preferences are, whether it’s I really don’t want to smoking weed or I really want you to be enrolling in these advanced classes and working hard in them is what we would call parent-teen contract. So, contract stipulates that A, if you perform the behavior well, there is something in it for you and not just the lack of a consequence but actually something that you can look forward to, and B, if you decide that you’re going to completely disregard the parents’ request of preferences, that there may be a negative consequence in there for you as well. So, for example, if your rule is that the teenager needs to have at least no missing assignments in their classes each week on Friday when you check their grades on the portal, and then you see that the teenager has a missing assignment, then perhaps ahead of time, you set up a consequence that you are not allowed to go out on the weekend until you complete that assignment, so that you can turn it in on Monday, right? And that’s a rule that is set up ahead of time, something the parents can monitor and something the parent can enforce. On the other hand, if the teen can go a whole month without many missing assignments, perhaps the parent is willing to let them use the car for the weekend, so there’s always something on both sides.

Sucheta: What I love about that is you are encouraging parents to make up their mind before the crisis or before the encounter in their teens. Second, you are encouraging the people to concretize these requirements or expectations in a much more explicit way and not implicit way which also really, really goes over where with concrete kids because that there is no room for argument, and the third is, I like that you are suggesting there is a balance between negative and positive consequences, but the student or the child, or the young teen is experiencing it, so it’s not something that’s suddenly [inaudible] that got dumped on a child of such.

I have a technical question for you which I run into sometimes, is the parents sometimes are inconsistent because they are going for convenience or they are short on time, or they have forgotten the rule they have come up with because they themselves may have some apple in a tree issue going on, so what are your suggestions in those circumstances?

Margaret: Well, first of all, I think from the get-go when working with families, it’s important to only come up with plans that everyone feels are realistic from the get-go, so I never want the plan to be my best idea. I want the family to really think through, what can we actually in theory make happen? And sometimes, as a professional working with a family, I have to go through and really test them on every possible scenario that could derail the plan and get them to think through, like how can we keep this plan going in spite of that, and I think just the way that you discuss and set this up can do a lot of that heavy lifting because you set up a plan that people feel good about, and then really helping the parents do the mental work about why they even want to do this in the first place, right? And allowing parents to reflect on their own goals as a parent, and how this particular plan or strategy would support those goals, helping them to kind of feel that at the tip of their tongue is all of the reasons that this is going to make their life easier, all the fights this might prevent and that really has to come from the parents’ own point of view and their own reflecting. I never share my opinions in any of that with them. I let them think about that in their own life for themselves.

Sucheta: I love that.

Margaret: And you know, when people have the right reasons for it and when people came up with a plan that at least one small step in the right direction that’s manageable for them, that doesn’t seem too complicated, then slowly over time, you try to put it in place and it’s not going to go perfect the first week, right? But when it doesn’t go well, it’s going back and it’s reflecting on what happened and whether it’s worth still trying to do the plan even if your best case scenario is being implemented three or four days a week. It’s not really about coming up with the smartest plan but just really helping people stay connected to why they want to do it in the first place.

Sucheta: And I love that you are talking about involving the whole family, so the parents are a team but they are also collaborating with their children, and then the therapist or the person who’s working with the family is coaching and guiding, so they become empowered to take their decisions which is very, very powerful. So, would this be replicable or is that model something we can use with teaching and the teaching context as well?

Margaret: It’s tricky in high schools and middle schools because teachers in those contexts have a lot on their plates. They usually teach over 100 students, they identify as people who are teachers of content areas like math or like science rather than somebody who is an elementary school education and spends all day with the same child. So, a lot of these techniques, I think, could be effective and at the same token, it may not be teachers who are in the best position in the school setting to deliver some of these strategies, and so actually, my team has been working in high schools to try to use some of the strategies with peers as the interventionists, and there’s two reasons for that.

Sucheta: That’s great.

Margaret: For one, if 11th and 12th grade students are capable of doing maybe just a kind of like basic version of these skills with ninth-grade ADHD students or 10th grade ADHD students who are a little younger than them, just those pieces of clarifying what your goals are, monitoring them and using some of the organization strategies that we can teach kids, those are being done in place, but a big piece of it is motivation like we talked about earlier, so most of the time, just teaching a kid with ADHD the skills isn’t going to be enough for them to do it. You need the constant monitoring and holding them accountable for using the skill. They have to know someone’s watching and someone cares if they do it or not. So, what a peer does is a peer provides a form of motivation, it’s a social form of motivation where I like this older student who’s giving me attention and I want them to like me back, some I’m going to try hard to impress them and work for them when they are encouraging me, and schools historically don’t have the financial resources to offer tangible rewards to students, and in addition, the rigid structure of so many high schools now with the way their schedules are set up and what kids can and cannot miss in terms of state testing and mandated curricula is not such that you can easily do things like give people free homework passes or other things that we might come up with, so I have worked a lot with schools that it’s just so hard for them to come up with natural reinforcers or rewards, so instead, we are trying to use the peers — social attention in place of that, and so far, it’s going pretty well.

Sucheta: And I love what, Maggie, you’re saying that it’s really hard to shift gear for teachers who are content experts to now become psychological content experts, and this does require a pretty thought-out psychological coaching in a way, and the second empowering thing about this model that you are describing, peer-to-peer mentorship, is it takes away this shame or embarrassment one might feel of being inadequate or being behind. It is having a peer just seems like somebody who is a few years or at least a year ahead of me who’s giving or parsing some wisdom that came from their experience, so it sounds to me much more relatable, right?

Margaret: Yeah, I think so. I mean, the kid’s conduit which is cool, they like it, and the best of the peer coaches are the ones who might have struggled a little bit themselves but now, they got the hang of it because they are the most relatable, like you say, so we are not always looking for the class president. Sometimes, we are just looking for a kid who has got a solid B average, who’s friendly and who’s willing to take the time and energy to spend 30 minutes to an hour a week helping somebody else out.

Sucheta: And such an act of generosity, that kid who used the strategies and now he’s mentoring, he gets to exercise some perspective taking and see the benefits of his own journey through passage of time.

So, as we end , I have a last question regarding accountability. Dealing with and supporting children, and adolescents with ADHD is a particular challenge as we have been discussing all along, but there’s a general sense of resistance to either ask for help or to accept help. How should we conceptualize the framework of making them engaged and accountable for their actions and particularly deal with this resistance that other person is making a big deal, and then it’s not really a big deal when I in fact now that when you talk, if they talk and to tell how big a deal it is to have so many setbacks on an ongoing basis, but somehow, it’s not my idea, it’s not a good idea kind of thought process?

Margaret: Well, one of the things that’s hard about being a teenager is you have all these ideas and these things that you want to do but you don’t feel like you have control of your own life, and so that’s hard, and I think that some of the conflicts that you are pointing out kind of comes from that. When working with teens, I think an approach that parents also can apply, teachers can apply, and therapists is just give them as much autonomy as you can. If you’re going to ask them to do something, let them choose how they do it, always explain to them why you want them to do it, so it’s not just because I said so, and give them a chance to say back with their thoughts are on that and make sure that you are not talking more than they are in a conversation. If you’re working with a kid and trying to empower them, then they should be doing more than 50% of the talking, and even if that means just sitting there and listening, and even if they won’t talk much, just waiting for them to be willing, there’s always something kids are willing to talk about, so sometimes, you have to start there and get to know them and what they are good at and what they are interested in. Eventually, you can kind of find that link between what you are hoping for them and what they are interested or willing to do at a given time.

Sucheta: That’s fantastic. That reminds me of a little episode or one of the researchers that I was describing, a teacher in kindergarten, she was finding that getting kids to take turns was really, really hard. They would read a book, then when the they are asked to share, everybody wanted to share, nobody wanted to listen, so she came up with this brilliant idea that she made a cut out of an ear and handed every student, every child a piece of ear, and whoever is holding an ear, it was their turn to listen, and the person who did not have an ear had to speak, so this way, she got them to listen. So, I feel in the context of adults talking to their teens, parents tend to interrupt or be bossy and lecture a lot. Maybe they should be holding an ear in their hands to remind themselves that it’s their turn to listen.

Margaret: Yeah, that’s nice.

Sucheta: Well, Maggie, this has been a fantastic conversation, I’ve always love your work, but I enjoyed the way you explain and make this research that you do translatable and something that people can implement, but most importantly, motivation is such a tricky matter and people complain a lot about children not being motivated but the strategies tend to be heavy: teachers becoming these cheerleaders or parents being cheerleaders or entertainers, and switching the focus on getting to see what the student wants, what the child wants, what the teen wants, and then crafting goals in tandem with their goals is a brilliant idea, and I really appreciate the work you have done for us and given us these tools to bring into our therapeutic sessions, so I thank you for that.

Margaret: Thank you.

Producer: Alright, well, that’s all the time we have for today, if you know of someone who might benefit from listening to today’s episode, we would be most grateful if you would kind of forward it directly to them.

So, on behalf of our host Sucheta Kamath, today’s guest Maggie Sibley, and all of us at Cerebral Matters, thanks for listening today and we look forward to seeing you again right here next week on Full PreFrontal.