Margaret Sibley My name’s Maggie Sibley, and I’m going to be talking about increasing self-motivation in young people with ADHD. And my disclosures are listed here on this slide, related to book royalties that I get for a book on a similar topic, as well as consulting that I’ve done with various healthcare companies and places that I receive research funding for. ADHD is a disorder that we consider to be a lifespan disorder, and it’s a disorder that we can now recognise in children as early as the preschool years. It’s well characterised during the elementary school-aged years, and it persists into adolescence in most children who are diagnosed with the disorder. ADHD also persists into young adulthood and into middle adulthood in most people who are diagnosed when they are younger, and there’s a family component of ADHD, such that if a child has ADHD, it’s also likely that one of their parents has ADHD, as well. And today, I’m going to be focused on what I would argue is one of the most vulnerable periods of life for a person with ADHD, which is the transition in the years leading up to young adulthood. One of the things you might hear is that people can grow out of their ADHD, the symptoms get milder as they get older, but in fact, the research suggests that as people with ADHD move through adolescence and enter young adulthood, that the gap between their peers and themselves actually widens, and they experience more impairments over time. What does it look like for a young adult with ADHD? Well, some of these statistics, to me, are really ex – surprising, and really – like, get my attention. So, first of all, a young adult with ADHD is 11 times more likely to be both unemployed and not in school at age 19, and for those who go on to seek university after high school, they are more likely to drop out and to fail courses. Those who go into the workforce are more likely to have trouble with keeping stable employment, they earn less at work, they have lower ratings by their supervisors, and they’re more likely to be living at home with family, as opposed to out in the world, living independently. Young adults with ADHD are having trouble establishing their financial independence, they’re less likely to have a credit card or a savings account, and they can have higher rates of food and housing instability, use of public assistance. In the end, young adults with ADHD say they have lower life satisfaction, higher rates of depression and are more prone to heavy use of substances, especially marijuana. These outcomes shouldn’t be alarming, but they should get our attention, and they aren’t set in stone, per se. So, what we know is that about half of children with ADHD will continue to experience the full disorder as adults, but about half will start to have a milder presentation, maybe only partial symptoms, and some even get really better to the point that we might call them recovered. So, as people who are trying to support young individuals with ADHD, of course, the key question becomes, what can we do to move more people into that group that is no longer experiencing ADHD in a full form as an adult? And to answer this question, I think we first have to understand where ADHD comes from. So, we’re going to take a little bit of a look at the biology of ADHD. Now, ADHD is considered a polygenic disorder, which means that there’s not one gene that makes someone have ADHD. Instead, there are a lot of little genes that add up, and if you have enough of them, you tend to be having enough symptoms that you look like a person with ADHD. And the genes that seem to be implicated in ADHD are genes that code for proteins that are the building blocks of neurons in the brain, and so that is why ADHD expresses itself, sort of, as a neurocognitive, or a neurodevelopmental disorder. Now, the neurons are the cells in the brain that determine the efficiency of how we think and how we act and what we’re able to accomplish and what we can do in our life. And although there’s several areas of the brain that are implicated in ADHD, the dopamine pathways and the activity of the neurochemical dopamine are – is, sort of, one of the central areas that relates to ADHD, and especially the area of motivation that we’re going to be talking about today. The people with ADHD, in general, have less sensitive dopamine receptors, as a result of how the building blocks of their brain are put together. And when a person has less sensitive dopamine receptors, they need higher levels of stimulation from their environment in order to recruit their neurons to get the same type of behaviour that somebody without ADHD might be able to enact with less stimulation. So, what does this look like? On average, people with ADHD might have less dopamine recruiting their actions in the brain, they might be less motivated by typical day-to-day situations because of the way their neurochemicals work. And when we think about what functions of the brain this impacts, one of the main ones is the executive functions that are housed in the prefrontal cortex. Now, in a typical adolescent, or a young youth who’s, like, pre-adolescent age, you’re going to see that these areas of the brain are not fully developed. Which means that youth have trouble setting long-term goals, they might not inhibit and monitor their behaviour as well as adults do, they have trouble with goalsetting, they have trouble with organising themselves, just in general, because of their age. We don’t expect those abilities to be fully mature until someone’s about 25 years old. But for teens with ADHD, these areas are doubly impaired. It’s almost like a double disorder of executive functions. And this is because of the way that the prefrontal cortex communicates with other parts of the brain and the architecture of the prefrontal cortex that don’t support healthy executive functions. The other piece is the way that we respond to rewards. So, dopamine is implicated in our response to rewards, and the strength of communication between the reward centres of our brains, for example, the striatum, and those executive functions, is attenuated, kind of, weakened, in people with ADHD. And so, people don’t feel as strong of a anticipation of rewards. They’re not as excited about things that are about to happen and so, their behaviour isn’t as impacted by the idea of something good happening, because I’m going to take this action, and what this does is it translates into motivation problems. We can see this in neuroimaging literature. So, in this study, it was a longitudinal study of children with ADHD and without ADHD, who went and had an MRI scan every couple of years, from about age eight to about age 22. And the blue line is children without ADHD, the red line is children with ADHD who still had ADHD as adults, and the green line is individuals who had ADHD as children but grew out of it as adults. And what we can see is on the brain images taken across adolescence, that around age 13, 14, 15, you actually see the green group leave the red trajectory on their brain imaging and join the blue trajectory. So, what this tells us is that there is some neuroplasticity, especially in adolescence, where the brain development of kids who have ADHD can get on a better track. And the areas that are implicated in this shift from a poorer trajectory to a better trajectory are in the executive function areas of the brain, the ability to self-monitor, the ability to enact goal-directed behaviours, to inhibit your behaviour. And those are, therefore, a key region that we might be thinking about when developing interventions and when trying to help build the skills of kids with ADHD. So, then as supportive adults, that leads us to the question of, what can we do to move teens with ADHD onto that better path? What clues do we have from the science? And I would argue that the first coping skill that might be obvious is teaching people executive function skills, specifically in the areas of organisation, time management and planning. Now, it’s important to know that our science hasn’t gotten to the place yet where we can effectively train the brain to look like a typically developing peer. However, what we can do is we can teach youths strategies to manage their ADHD symptoms and to compensate for the executive function difficulties they’re having. So, for example, I can’t improve the memory of a teen with ADHD, but I can teach them that if they have trouble with forgetfulness, they need to be the kind of person that always writes everything down. I can’t necessarily make somebody less likely to tend towards messiness and chaos in their room and in their belongings, but I can teach them that we can set up a system that we follow to keep school materials orderly, and they can learn to use that system over time. And we can go through examples like this for time management, for memory strategies to study for tests, for decision-making and how to think carefully and not impulsively about interpersonal situations, for strategies for getting homework done and avoiding procrastination. And this isn’t rocket science, so people have been teaching and using these strategies with youth with ADHD for decades, and most of it started in schools with Special Educators. And you might have a child who goes to a resource room or has a special aide that comes in and helps them organise their materials once or twice a week, maybe helps them fill out a planner, or maybe helps them fill out a schedule, studies with them. Lots of skills and strategies that we can use with kids with ADHD to help them overcome their deficits. The thing is, though, these strategies, though helpful, are maybe only partially doing the job. They teach kids what they should be doing, but they don’t necessarily address getting the kids to use these strategies independently, by themselves. And so, that is still a question of motivation. How do we motivate youth to want do to this stuff that they’ve been shown? And I work in a clinic, and we see a lot of families of teens with ADHD. We did a study where we audio recorded over 1,000 sessions of adolescents with ADHD working with Therapists, working with the parents in the room, as well. And we were able to listen into those sessions and find the top barriers and reasons that teens with ADHD were not following through on using the skills that they were being shown in the therapy. And the number one reason, three out of four teens was heard saying that they don’t like the skills, that they don’t want to use them because they just don’t feel like it’s something that is palatable to them. There were also reasons that came up related to the parents. Some of the parents were saying they were having trouble holding the teens accountable for using the skills. The parents just, sort of, were hoping that the Therapist could teach the teen the skills, and the teen would use them, and the parent didn’t have to get involved and, sort of, reinforce that use. We had teens who wanted to use the skills but were forgetful. We had teens that believed they were fine and didn’t need the skills. We had teens that felt like, “Even if I learn this, it wouldn’t help me anyway, ‘cause I’m just not good at anything.” And we also had parents who were helping so much and providing so much assistance, that the teens didn’t even have an opportunity to do things independently. So, there was a mixed bag of reasons why teens don’t seem to use what we’re teaching them. And so, if we are going to target the motivation of adolescents with ADHD, it’s clear that we need to be thinking both about the roadblocks for the youth and how we can address those, but also about the roadblocks for the adults in their lives. Because if accountability from adults is a key piece of the picture, then we need to equip adults with the strategies to promote that accountability. Now, in the work my team has done, we’ve spent a lot of times getting to know parents and having them fill out questionnaires for us on what it’s like to parent an adolescent with ADHD, and we learn from them. And in one study we did with over 300 families, we had parents share with us, sort of, their styles of how they helped their kids in school. And on one side, we detected a pattern held by a lot of the parents in the group, where they felt like the youth’s Personal Assistant. Where they were overly involved in all aspects of schoolwork, whether that was helping with homework and sitting down with them, looking at their grades online and trying to problem solve missing work. Whether it was communicating directly with the Teacher. And sometimes these parents resorted to a lot of taking things away because they felt like they didn’t know what else to do in order to get the adolescent to produce more. So, this Personal Assistant group would run – ring true for a lot of people. We also had another group of parents who felt burned out and, like, they, kind of, maybe used to be like that Personal Assistant, but at this point have to, sort of, let go, accepted that they couldn’t help, and expected the adolescent to, basically, be on their own at this point. The trouble is – there’s trouble with both of these sides, right? They’re both the extremes, and in one case, the teen doesn’t have the opportunity to become independent, because they’re getting so much help. And, on the other side, there’s no-one, sort of, supporting and encouraging the adolescent to perform. They don’t have structure in place, there’s no-one who, kind of, is aware of how they’re doing and is trying to problem solve with them. And so, really what we were, kind of, trying to advocate for is something in the middle, right? Where you have a little bit of support and assistance, but you also have enough space and autonomy to be at that age doing things on your own. Now, how have we historically addressed motivation deficits? Well, rewards is the classic ADHD treatment strategy, as anyone who’s done behaviour therapy or delivered behaviour therapy knows. And in this situation, an adult will create a relationship between something the teen enjoys and something that the teen needs to get better at, something we might call a target behaviour. Now, if we go back to the brain differences of a teenager with ADHD, we need to look for ways to turn up that dopamine sometimes, so that there’s more interest in pursuing possibly a boring or aversive activity to the teen, right? And so, the idea is that rewards increase the value of doing an undesirable behaviour, that, basically, if you don’t want to do your homework and I say, “As soon as you get your homework, you know, I’m going to let you play videogames for two hours,” the teen would have more of a reason to do the homework, because they want to get to those videogames. This is a simple idea, it’s the classic strategy in the toolbox, and it’s certainly a tool that I think is valid for certain situations. The downside of this is although it addresses short-term motivation, it does not necessarily address long-term motivation. It’s not necessarily a sustainable strategy over time, and it certainly doesn’t address self-motivation, because you still need the adult to implement the reward with the teenager. And so, it’s a tool in the toolbox, but it doesn’t address the whole story. So, then, what are the other chapters in this story? So, there are a lot of different elements to the motivation deficits of adolescents with ADHD. It’s a puzzle that we, kind of, have to put together to see the whole. Now, because of some of the ways that the chemicals in their brains are acting differently, it’s not surprising they have – teens with ADHD have lower interest in everyday tasks. Lower interest in things like reading a book, potentially, or lower interest in engaging in schoolwork, or in listening to somebody else tell their story, you know, listening in a conversation. They’re also less motivated by the natural rewards in the environment, things like getting an A on a test, or being invited to do something on the weekend with a friend. Unless it’s a key area of interest for the teen, they gen – in general, on average, are less motivated by these natural rewards in our environment. There are also environmental effects on people’s motivation. So, for example, if you’ve heard and gotten the message for years that you’re not as good as other kids at things, you’re going to start to believe that, “Maybe I’m inferior to other people, maybe there’s something about me that’s broken. I just can’t succeed, why try?” Like we just mentioned a moment ago, as well, there’s a scenario where a lot of teens with ADHD are actually having lower and lower autonomy over time because they are getting so much help and support from other people, that they’re, sort of, never held accountable to do things on their own. And so, when you feel like, “Well, you know, I don’t do things on my own, I just wait for someone to tell me to do it,” that also can undermine self-motivation. Teens with ADHD are less interested in pursuing long-term goals, like getting into college or trying to save up money. Teens with ADHD have trouble with consistency. When things are novel, they have their attention for a little while, but once that novelty wears off, you know, they’re left with less reasons and less natural reinforcers in the environment to sustain, you know, productive actions. They can develop beliefs, like, change feels impossible, why try? They can forget, because they’re forgetful, why they care about things, what their reasons are for, you know, doing this homework assignment that feels boring. And they also lack a sense of urgency, often, because they need immediate reinforcement to make them feel like, “Oh no, I’ve got to get my act together.” So, whenever that sense of urgency is not in place, they seem like they don’t care, and so, that’s another complaint that we often hear from families, is that they’re having trouble getting kids to do something unless it’s really urgent. Well, if there’s all these different pieces of the puzzle of motivation for teens with ADHD, then our approach for helping also needs to be a multipronged approach. There’s not going to be one silver bullet. Instead, we have to figure out specific, little things that can all come together and help with the situation. Now, I’m going to go over nine actions that are things that supportive adults can do every day to help support development of healthy motivation systems in adolescents with ADHD, so that as they approach the young adult years, we’re hopefully getting them to a place where they’re able to be independent and autonomous and have, sort of, self-motivation in life. The first one on the list is to help teens with ADHD discover their interests. So, the motivation system that’s generally intact in people with ADHD is pleasure-based motivation. So, you may see that when your teen is very interested in something, they have no trouble being engaged and motivated. For teens with ADHD, we can leverage that. We have to help them, sort of, organise their life around the things that they’re naturally interested in, and that means that they may need to pursue educational tracks and careers that are based on these high interest areas. We have to make sure, though, that they’re pursuing productive and healthy interests that could actually lead to a likely chance of a successful career or educational path, or even a hobby, versus something that might be a longshot and might be unlikely to pan out for them. So, parents and other adults often have to think about this and, sort of, consider and notice, what is the teen interested in? And maybe, also, get them involved in a lot of extracurricular activities, where they can be exposed to areas that might deviate from the standard curriculum that they’re exposed to in their school, which they might not be finding that interesting. Number two, so watch for environmental fit. So, it’s really important that we find environments that value the strengths of teens with ADHD, so they are getting positive feedback for who they are, and, also, avoiding environments that might lead to demoralisation. So, if we notice that it’s a situation at school or with peers, or anywhere else that the adolescent spends time, that really is coming down hard on them for what they’re not good at, we might need to reconsider whether that’s a healthy place for them to be. We also need to gather information about a wider range of environments that the teen could be in, to make sure that we’ve, sort of, assessed what might be the best fit for them. Whether that’s finding out all the possible schools that they can go to, and learning and researching which ones might be the best fit, or picking peer groups or extracurricular activities, or even families that your family spends time with that you think will build up your teen and help them be able to succeed. Number three is to use baby steps when setting goals. So, we all have a tendency to, sort of, want to set a goal based on where we eventually want to end up. But for teens with ADHD, progress is often slow, and they need to see themselves succeed a little bit along the way to keep going. And so, to have small, tiny goals that they can actually achieve, that feel like meaningful and achievable, and to set those little baby steps a few at a time, is a great way to, kind of, build motivation in teens with ADHD. We want to make sure that we’re building goals based on behavioural things that teens can do, instead of, overall, you know, good performance. I want to see improvement, I don’t want to see excellence, essentially. And making sure, also, that those goals are meaningful to the youth. Number four is creating accountability and limits for teens with ADHD. Although we really want to support autonomy and have teens with ADHD be able to do things independently, we also know that they struggle with decision making, and, often, don’t know how to brakes on their own behaviour. And so, as adults in their life, we do have to put up guardrails for them sometimes, which means setting certain limits. If we’re setting consequences for teens with ADHD, we need to make sure that those are set in advance, so that they can be predictable for the teens and help with their decision making and weighing the pros and cons of a certain action that, potentially, could get them in trouble. We want to make sure that parents are only announcing consequences that they expect to follow through on, and being consistent with the implementation of those consequences. As it turns out, in the research, small, consistent consequences for negative behaviours is actually more impactful than a big consequence, like grounding, that happens every now and then. And, also, it’s important that the punishment fits the crime. So, we don’t want a situation where an adolescent’s done some small mess up and they have some huge punishment. We also want to look for opportunities to have learning experiences out of a punishment. So, if you are disrespectful of a family member, maybe writing an apology letter. If you snuck out and did something you weren’t supposed to on the weekend, maybe the following weekend you stay in and you help, you know, clean out the garage. Number five is to keep a consistent home routine, and this is something that’s tricky, because teens with ADHD love unstructured environment. They love not to be told what to do. They love to just be able to go with the flow and do what they feel like, but unfortunately, those are the types of environments that they struggle most in, even though they might like it. And so, you know, adults are, sort of, given the task of creating a consistent structure and home routine, at home. Teens with ADHD need that structure even more than kids without ADHD. Now, you can be strategic. There’s ways to build in incentives. For example, maybe we have a rule at home that after homework, then you get to do electronics, and that way, we’re building in an incentive, just in the way our house works, of getting our homework done. Another example is, maybe you want to have your kids take a break when they get home from school, to be able to relax a little bit. Be strategic, maybe that break involves something with a clear end time, like a show that ends on Netflix. When the credits roll, we turn off the television, we go do homework. Instead of something like a videogame that never really ends, and then we get in arguments about, “Five more minutes,” and that can spiral out of control, as a lot of people know. Even simple things, like in our family we do all the dishes and clean up the kitchen before we eat dessert, for example, can help avoid arguments, prevent the need for reminders, and also, minimise punishments. Number six is to manufacture opportunities for autonomy. So, teens with ADHD unfortunately have a lot of opportunities for autonomy taken away from them. They’re not voted on to be a leader at school. They may not be given special privileges, and you may feel need to have – take back the reins on some of what they’re allowed to do, because you don’t think they can handle it responsibly. To make up for that, you need to manufacture additional opportunities for autonomy that are safe and aren’t going to get them in trouble, but can still develop those same skills. So, for example, looking for extracurriculars that build on leadership and build on decision making, planning, self-sufficiency, whether that’s something that kids do over the summer or after school. You might have to go out of your way to research what’s available in your community, to get them involved in things. You also may just find things that you can have them do to help around the house, to help build opport – or to help build independence. So, for example, maybe you have them cook dinner every Friday and plan the meal. Maybe you have them go – take shopping lists for you and come back and get things you need, things that allow them to be independent. Planning something for your family to do on the weekend. If they mess up, it’s low stakes, right? But it still gives them the opportunity to try things out and to be in charge of something, which is a skill that can be hard for teens with ADHD. Number seven is building self-confidence. So, the research shows that adolescents with ADHD have lower self-esteem with peers. This is because of the negative feedback they get for years from their environment. The only way to offset negative in – feedback and those beliefs that are being developed about the self, is to give them concrete evidence that they can see, that contradicts those beliefs. And so, here we want kids to see themselves being good at things, and so, you may have to go out of your way to notice what your child is good at, and help them develop skills to get even better at that thing. You also need to make sure you minimise negative feedback from other people. So, making sure they’re surrounding themselves with kids that build them up, helping them find friends that might share their interest, especially if those friends can be in person, rather than online. Those – that social acceptance that you can see with your own eyes is powerful, and can help kids feel like they are a worthwhile person, that other people do accept and like them. And then, even in the little interactions at home, draw attention to the good things your teen does. Notice when they do something correctly without being asked, or when they take that extra effort to clean up after themselves, and just thank them for that, acknowledge them. We want to create a situation where they’re hearing more good things about themselves than bad. Number eight is one little thing you can do that I think maybe goes the longest way for families, if they do this consistently over time, which is to hold a weekly meeting with the teen, to have proactive, rather than reactive, discussions, of hot topics or areas that the teen’s struggling with. So, you want to pair this meeting with something enjoyable, go to the coffee shop together, go take a walk, go sit at home, turn on some music that you both like, and relax, so that it’s positive and it’s something you look forward to. And then have meeting topics decided in advance. For example, you might want to recognise all the positive things the teen did last week. You might want to pull up their grades online together and discuss missing assignments, or what the strategy is to bring up a grade. You might want to plan ahead for the upcoming week, problem solve things that are tricky. And then there can also be, sort of like, one time conversations, like getting ready for the summer and talking about what activities the teen’s going to be involved in, or maybe working together to pick your high school courses for next year. Asking the teen if there’s any freedoms that they want to start trying to earn, and mapping out what that could be. Having that, kind of, regular conversation not only builds positive relationships, builds positive communication with each other, but it also gives an opportunity for you to bring up topics when everyone’s calm. And finally, make sure your communication style during this meeting, or at other times, is one that would empower the youth to, sort of, develop their own self-motivation. So, you want to make sure that you don’t argue with teens or try to persuade them with their – with your logic. I guarantee you that even if you have the most compelling arguments laid out for whatever your point is, if your teen is not interested in what you have to say, it won’t matter. And so, being coercive, trying to shame them, those things aren’t really productive. Instead, I’m going to lay out a few strategies that I’ve borrowed from motivational interviewing, which is a counselling style designed to empower people to find self-motivation. And I think not just Counsellors can use this style, parents can use this style, Teachers can use this style, any supportive adult can do so. Some of the key ideas here are that we want to give our positive attention in a conversation to anything productive that the teen is bringing to the table. See what motivation is already there and get them to talk more about that. Give attention to their own ideas about things they’d like to change. When the teen brings up counterproductive ideas, don’t argue with them. Just don’t give them a lot of oxygen, don’t give them a lot of attention. Switch the conversation to something else. We want to make sure that we’re finding opportunities to emphasise the teen’s autonomy in the conversation, saying things, like, you know, “You know yourself best, why don’t you make this decision?” When the teen does things that are positive, we want to affirm them, we want to show our confidence in them for the decisions that they’re making. And really, like, think about your listening skills. Do your listening skills need brushing up? Do they show the teen that you’re listening and that they’re being heard, and that you’re understanding their point? And if not, working on how you listen to your teen. One way to get teens to open up is to make sure you’re asking them open ended questions instead of closed ended questions, things like, “What would you like to work on?” instead of, “Do you want to work on this?” which only gets a yes or no answer. And then, when you can, try to take off your authoritarian hat and just come alongside as, like, human to human with the teen. Make them feel like you accept them no matter where they’re at, so that they become more vulnerable, the conversation becomes more open, and it avoids a power struggle. In the end, I think we want to try to ask teens to do the work, right? Have them make the plan. You give them feedback on their plan, and sometimes their – you know their plan is not a good idea, but let them do the plan anyways, and let them see with their own eyes that it didn’t work, ‘cause that can be more powerful than taking your word for it. So, I’m going to give a final thought, which is that you guys are going to do a lot of things to support your teen, take a lot of actions that are not going to show immediate results. They may not show results for ten years. It’s the accumulation of all the little things that you do every day that matter, not the one silver bullet idea that you have. Even though some of these actions are not going to show immediate results, do them anyways. Keep the faith that these things will work and they will add up if you just stay consistent. Honestly, it’s the small things that we do over time that make the biggest difference. As far as a few resources, if you’re interested in reading in-depth about the motivational interviewing strategies I mentioned on that last slide, this is the book on motivational interviewing that people can read. And if you scan the QR code that’s on this slide, you also can go to the website and learn about ways to get trained in this approach, if you’d like to go to a workshop on it. Also, I have a free article that you can scan this QR code for, and that article will allow you to read more in-depth about the nine parenting strategies that I mentioned on these slides. And so, just to wrap up, I want to think everyone for their support, for taking the time to listen to this presentation, and my website is on here below. That’s the best way to learn more about what I do and also, to get in contact me – with me, if you want to ask any questions or share anything with me. Thank you so much.