Communication Series: Steps Toward Better Connections (EP 58)

Join Dr. Regan for this second episode of the Powerful Self-Care Series. Rather than becoming the victim of an intense world, constantly in survival mode, learn strategies to become effective with self-care. This episode focuses on how to reduce draining inputs in order to budget your resilience.  Explore Dr. Regan's new Learning and Equipping page and the specific course page for "Empowered Parenting."  Dr. Regan's Resources: Zur Institute courses for clinicians Understanding Autism in Adults and Aging Adults, 2nd ed Audiobook Book: Understanding Autistic Behaviors Autism in the Adult website homepage Website Resources for Clinicians    

Join Dr. Regan for this first episode of a new self-care series. Rather than becoming the victim of an intense world, constantly in survival mode, learn strategies to become powerful at self-care. The first step is self-awareness which can begin by noticing your fight, flight, freeze, and physical reactions to events and experiences.  Explore Dr. Regan's new Learning and Equipping page and the specific course page for "Empowered Parenting."  Dr. Regan's Resources: Zur Institute courses for clinicians Understanding Autism in Adults and Aging Adults, 2nd ed Audiobook Book: Understanding Autistic Behaviors Autism in the Adult website homepage Website Resources for Clinicians    

Join Dr. Regan for the third and final episode of the Communication Series. This episode highlights ways to communicate while talking about challenging topics.    Explore Dr. Regan's new Learning and Equipping page and the specific course page for "Empowered Parenting."    Dr. Regan's Resources: Zur Institute courses for clinicians Understanding Autism in Adults and Aging Adults, 2nd ed Audiobook Book: Understanding Autistic Behaviors Autism in the Adult website homepage Website Resources for Clinicians    

Join Dr. Regan for the second episode in the Communication Series. This episode highlights ways to use communication to protect and grow relationships.    Dr. Regan's Resources: Zur Institute courses for clinicians Understanding Autism in Adults and Aging Adults, 2nd ed Audiobook Book: Understanding Autistic Behaviors Autism in the Adult website homepage Website Resources for Clinicians    

Join Dr. Regan for the first episode of the new Communication Series. This first episode highlights moments of connection, such as talking in the car, going out on date night, and catching up with a friend. Tune in to hear what to avoid and what to focus on to enhance connection.    Dr. Regan's Resources: Zur Institute courses for clinicians Understanding Autism in Adults and Aging Adults, 2nd ed Audiobook Book: Understanding Autistic Behaviors Autism in the Adult website homepage Website Resources for Clinicians      

In this third episode of the executive function series, Dr. Regan discusses sticking, releasing, and switching gears in everyday life.  Related resources: Podcast Episode: Autism and "Just Right" Podcast Episode: Gaining Momentum for Activities Amazon: Time Timer (I don't receive any income from your purchase)   Dr. Regan's Resources: Zur Institute courses for clinicians Understanding Autism in Adults and Aging Adults, 2nd ed Audiobook Book: Understanding Autistic Behaviors Autism in the Adult website homepage Website Resources for Clinicians    

The Holidays and Autism: Holding Fast and Letting Go Planning a Merry Holiday on the Autism Spectrum

In this second episode of the executive function series, Dr. Regan breaks down how speed, working memory, and sequencing impact daily life.  I Love Lucy chocolate factory TV clip Executive Function Book Series by Dawson and Guare: Smart But Scattered (children's version) Smart But Scattered (Teen version) Smart But Scattered (adult version)   Dr. Regan's Master Class for Clinicians (Sept, Oct, Nov, Dec 2023) Zur Institute: Master Class   Dr. Regan's Resources Book: Understanding Autism in Adults and Aging Adults, 2nd ed Audiobook Book: Understanding Autistic Behaviors Autism in the Adult website homepage Website Resources for Clinicians Read the transcript:  1 00:00:05,570 --> 00:00:06,059 Hello, 2 00:00:06,070 --> 00:00:06,820 everyone. 3 00:00:06,829 --> 00:00:08,659 This is Doctor Regan. 4 00:00:08,670 --> 00:00:13,670 I'm joining you for an episode of Autism in the adult podcast. 5 00:00:14,020 --> 00:00:14,880 For those of you. 6 00:00:14,890 --> 00:00:16,260 New to the podcast. 7 00:00:16,270 --> 00:00:18,020 I'm a neuropsychologist, 8 00:00:18,030 --> 00:00:20,190 a certified autism specialist, 9 00:00:20,420 --> 00:00:25,180 and the founder and director of an autism diagnostic clinic for adolescents, 10 00:00:25,190 --> 00:00:28,940 adults and aging adults in Central Illinois. 11 00:00:29,549 --> 00:00:35,240 And today you are listening to the second episode in a series on executive function. 12 00:00:35,750 --> 00:00:47,139 And this is a topic we're covering because many of the strengths and challenges that go along with the autistic neurology fall within the realm of executive function. 13 00:00:48,849 --> 00:00:51,619 Before we dive into that topic for today, 14 00:00:51,759 --> 00:00:58,540 I'd like to thank Amanda who pointed out that my diagnostic terms in the first episode were imprecise. 15 00:00:58,830 --> 00:01:03,279 I use terms that are common in my day to day interactions with patients, 16 00:01:03,290 --> 00:01:04,819 families and physicians, 17 00:01:05,080 --> 00:01:07,900 which are the terms ADD and ADHD. 18 00:01:08,089 --> 00:01:09,099 However, 19 00:01:09,110 --> 00:01:16,800 the most precise and current terminology is ADHD predominantly inattentive presentation. 20 00:01:17,379 --> 00:01:21,389 ADHD predominantly hyperactive -  21 00:01:21,470 --> 00:01:26,199 impulsive presentation, or ADHD combined presentation. 22 00:01:27,379 --> 00:01:29,589 And I guess in reviewing that in my mind, 23 00:01:29,599 --> 00:01:32,720 I think it's similar with the term dementia, 24 00:01:32,730 --> 00:01:37,550 which is often still used in day to day language in clinical settings, 25 00:01:37,559 --> 00:01:42,690 even though the most recent and precise term is major neurocognitive disorder. 26 00:01:43,360 --> 00:01:43,650 So, 27 00:01:43,660 --> 00:01:44,410 thanks Amanda, 28 00:01:44,419 --> 00:01:51,279 I'll stick to being precise and specific in podcasts about the topic of ADHD 29 00:01:51,839 --> 00:01:55,230 And instead of using each of the subtypes, 30 00:01:55,239 --> 00:02:07,379 I will just use the term ADHD unless I'm speaking about specific features of one subtype. As we discussed in the first episode, 31 00:02:07,389 --> 00:02:16,580 executive function is really a broad term and it's includes multiple subfunctions or subcategories. 32 00:02:17,179 --> 00:02:33,800 And this is a series that I really encourage you to listen to the first episode before listening to subsequent episodes because it really went through a lot of layers of explaining executive function, ADHD, and autism ... 33 00:02:34,350 --> 00:02:37,160 how those relate or don't relate to each other. 34 00:02:38,539 --> 00:02:43,720 So the subcategories of executive function include things like attention, 35 00:02:43,990 --> 00:02:45,919 goal directed persistence, 36 00:02:45,929 --> 00:02:47,949 organization, response 37 00:02:47,960 --> 00:02:50,020 inhibition and several more. 38 00:02:50,440 --> 00:02:50,990 In fact, 39 00:02:51,000 --> 00:02:53,229 depending on what source you're using, 40 00:02:53,240 --> 00:02:57,669 there can be about 12 or so sub functions identified, 41 00:02:57,679 --> 00:03:06,410 even though there's really no complete agreement on how to list out the sub functions within executive function. 42 00:03:08,110 --> 00:03:17,000 There are two main developmental diagnoses with large executive function components and these include ADHD and autism, 43 00:03:18,710 --> 00:03:23,160 the ADHD criteria, as we talked about in the previous episode, 44 00:03:23,339 --> 00:03:28,899 only describe symptoms falling within about four of the subcategories. 45 00:03:29,720 --> 00:03:35,460 I would label these subcategories in the ADHD as organization, 46 00:03:35,500 --> 00:03:41,690 attention, response inhibition, and goal directed persistence. For example, 47 00:03:41,699 --> 00:03:50,500 "fails to give close attention to details or makes careless mistakes" is one of the criteria that can be met in ADHD. 48 00:03:50,919 --> 00:04:08,720 And I would say that, as a symptom, that falls within the subcategory of attention. "Blurts out answers before questions have been completed" is an ADHD symptom that falls within the executive function 49 00:04:08,729 --> 00:04:13,100 subcategory of response inhibition. 50 00:04:13,809 --> 00:04:20,420 So is somebody able to inhibit or stop a response until they think it through? 51 00:04:21,890 --> 00:04:31,679 So autism will present with core executive function features in some combination as well across the totality of the 12 categories. 52 00:04:31,959 --> 00:04:40,040 And these features are some of the strengths and gifts within the autism presentation. 53 00:04:40,049 --> 00:04:45,309 and also some of the challenges. In this episode, 54 00:04:45,320 --> 00:04:48,559 we're going to focus on the executive function  55 00:04:48,570 --> 00:04:53,600 sub features of working memory, speed, and sequencing. 56 00:04:54,100 --> 00:05:01,769 And I've chosen these abilities to highlight together because we often use them together to accomplish daily tasks. 57 00:05:02,059 --> 00:05:06,010 And I'm hoping that in explaining them and presenting them together, 58 00:05:06,049 --> 00:05:14,709 you'll be able to watch yourself or watch other people in your life to see how these executive function abilities work for them. 59 00:05:16,929 --> 00:05:18,720 Similar to the last episode, 60 00:05:18,730 --> 00:05:22,329 I'm going to walk you through various levels of information. 61 00:05:22,339 --> 00:05:24,940 So stick with me. 62 00:05:24,950 --> 00:05:34,839 First, I want to make a comparison between the center of the brain, which is called the subcortical areas, and a conveyor belt. 63 00:05:35,600 --> 00:05:36,329 You'll, 64 00:05:36,339 --> 00:05:41,320 you've probably heard that the brain has both gray matter and white matter. 65 00:05:42,929 --> 00:05:44,720 The outside of the brain and  66 00:05:45,089 --> 00:05:54,059 certain areas in the center are gray and these gray matter sections are connected by white matter tracts. 67 00:05:55,109 --> 00:06:04,440 The color white comes from the fact that there's a fatty substance called myelin covering these neuron tracks. 68 00:06:04,450 --> 00:06:13,290 And the presence of the fatty covering allows the nerve signals to travel faster than without that covering. 69 00:06:13,399 --> 00:06:19,579 So the center of the brain impacts speed of thinking and processing. 70 00:06:20,540 --> 00:06:23,829 So in conditions like multiple sclerosis, 71 00:06:23,839 --> 00:06:24,989 for example, 72 00:06:25,000 --> 00:06:27,869 where you have demyelinating, 73 00:06:28,410 --> 00:06:31,989 that is the white matter starts to degrade, 74 00:06:32,000 --> 00:06:37,029 one of the features can be a slowing of processing. 75 00:06:39,200 --> 00:06:51,100 So the first point is that speed is a function of the subcortical pathways that impact executive function and several autistic characteristics. 76 00:06:51,109 --> 00:06:55,640 So we do want to focus on this subcategory of speed. 77 00:06:57,649 --> 00:07:01,179 Another subcategory is working memory. 78 00:07:02,950 --> 00:07:05,600 What is this part of executive function? 79 00:07:05,869 --> 00:07:06,160 Well, 80 00:07:06,170 --> 00:07:08,880 even though we call it working memory, 81 00:07:09,239 --> 00:07:16,350 a neuropsychologist or a cognitive scientist might say it's actually really more attention than memory 82 00:07:16,829 --> 00:07:30,880 in that it has to do with the amount of information a person can hold within their attention without storing it by really memorizing it for later. 83 00:07:31,700 --> 00:07:35,589 So it usually doesn't end up in permanent memory. 84 00:07:35,929 --> 00:07:40,670 But we're able to hold information our in our attention. 85 00:07:41,549 --> 00:07:54,390 And some people have a really strong working memory and others really struggle with this. And you'll see different estimates probably about how large working memory generally is. 86 00:07:54,779 --> 00:08:02,779 But most times a person can hold about five plus or minus two bits of information in their attention. 87 00:08:03,679 --> 00:08:07,209 This makes sense because if you were 89 00:08:07,769 --> 00:08:12,690 using phones in the old days where we didn't have cell phones and 90 00:08:12,700 --> 00:08:14,670 phone numbers in our phone ... 91 00:08:14,970 --> 00:08:20,799 a lot of times someone would tell us their phone number or we'd look at it in a phone book and we'd have to 93 00:08:21,149 --> 00:08:26,350 kind of rehearse it in our working memory while we dialed. 94 00:08:26,359 --> 00:08:31,489 So we held seven digits ... in those days... 95 00:08:32,190 --> 00:08:38,090 in our mind while we pushed in the information to the phone. 96 00:08:40,789 --> 00:08:43,140 So let me give another illustration. 97 00:08:43,299 --> 00:08:45,469 Working memory is what we use, 98 00:08:45,479 --> 00:08:46,309 for example, 99 00:08:46,320 --> 00:08:48,609 if we hear an instruction with ... 100 00:08:48,619 --> 00:08:52,099 let's say three parts to it and we go to carry it out. 101 00:08:52,559 --> 00:08:57,010 Our boss may ask us to print the schedule for the day, 102 00:08:57,250 --> 00:09:01,809 put a copy on her desk, and check the phone messages from overnight. 103 00:09:02,929 --> 00:09:07,559 So we have to keep these tasks in mind while doing them. 104 00:09:07,570 --> 00:09:11,359 We have to hold them in our mind. 105 00:09:11,500 --> 00:09:15,849 And although we may recall the sequence of requests later in the day, 106 00:09:15,859 --> 00:09:22,320 we're unlikely to remember them in a month or a year because we haven't memorized them. 107 00:09:23,299 --> 00:09:25,190 But while we're carrying them out. 108 00:09:25,200 --> 00:09:31,179 We may be able to keep them in mind because they're in our working memory. 109 00:09:31,450 --> 00:09:37,469 So the term working means that we keep things in mind while we're using them. 110 00:09:37,479 --> 00:09:44,950 I'm using this information of what the three tasks are while I'm accomplishing the tasks. 111 00:09:46,280 --> 00:09:50,619 Working memory is what we use when we walk into a room for something. 112 00:09:50,900 --> 00:09:55,950 And then sometimes if the information has left our working memory, 113 00:09:55,960 --> 00:09:58,270 we feel frustrated that oh, 114 00:09:58,280 --> 00:10:01,869 I walked into a room to get something and now it's gone. 115 00:10:02,109 --> 00:10:05,489 That's something that has slipped through our working memory. 116 00:10:07,250 --> 00:10:08,229 Similarly, 117 00:10:08,239 --> 00:10:09,299 we may say, 118 00:10:09,309 --> 00:10:09,340 oh, 119 00:10:09,349 --> 00:10:10,219 shoot, 120 00:10:10,229 --> 00:10:12,599 I was going to say something or ask something, 121 00:10:12,609 --> 00:10:14,000 but I forgot what it was. 122 00:10:14,859 --> 00:10:21,489 We were keeping it in our mind while the other person finished their sentence. 123 00:10:21,500 --> 00:10:24,179 But then by the time they were finished, 124 00:10:24,229 --> 00:10:27,229 our thought had slipped through our working memory. 125 00:10:27,239 --> 00:10:30,789 It wasn't held the way that we wanted it to be. 126 00:10:30,799 --> 00:10:36,770 And so we were unable to bring it back when the person, 128 00:10:37,960 --> 00:10:39,789 signaled that it was our turn. 129 00:10:42,080 --> 00:10:51,950 So to summarize our abilities within executive function stem anatomically from the center and the front part of the brain pathways, 130 00:10:51,960 --> 00:10:55,780 the subcortical pathways that connect with the frontal lobes. 131 00:10:55,789 --> 00:11:01,719 And these pathways include white matter which impacts how quickly someone can think, 132 00:11:01,729 --> 00:11:03,340 process and respond. 133 00:11:03,900 --> 00:11:08,130 And this part of the brain also impacts working memory, 134 00:11:08,140 --> 00:11:14,349 which is our ability to hold information in mind while we work with and use it. 135 00:11:15,409 --> 00:11:26,900 So let's tie these concepts speed and working memory with the conveyor belt image that I mentioned earlier in the talk about the third piece for today, 136 00:11:26,909 --> 00:11:36,059 which is sequencing. A sequence of something is the order in which the things occur or they're arranged. 137 00:11:36,270 --> 00:11:41,020 And when we listened to our boss ask us to do three things, 138 00:11:41,030 --> 00:11:44,210 she presented them in a certain sequence. 139 00:11:44,219 --> 00:11:46,349 And when we listen to someone, 140 00:11:46,789 --> 00:11:50,820 the words and their meanings and concepts, 141 00:11:50,830 --> 00:12:00,309 these come toward our ears and into our brains as sequences of data. Picture that conveyor belt. 142 00:12:00,320 --> 00:12:01,109 Now, 143 00:12:01,440 --> 00:12:07,289 a conveyor belt is a surface that moves and it brings items to you. 144 00:12:07,809 --> 00:12:15,039 A person in a factory may work with items coming toward them on a moving surface. 145 00:12:15,380 --> 00:12:18,630 Perhaps they're employed to sort the items. 146 00:12:18,710 --> 00:12:19,869 For example, 147 00:12:19,880 --> 00:12:23,859 here come green and red candies. 148 00:12:23,869 --> 00:12:40,484 And I'm employed to take the green candies coming toward me and put them in the green box and to take the red candies and put them in the red box. Or maybe someone's employed to assemble something. As the item comes toward you, 149 00:12:40,494 --> 00:12:42,385 you add this piece, 150 00:12:42,395 --> 00:12:50,575 then you place it back on the moving belt and the next person will add the next piece and so forth. 151 00:12:50,585 --> 00:12:54,804 So items come to you in a sequence, 152 00:12:54,815 --> 00:12:57,205 one item after another, 153 00:12:57,215 --> 00:12:58,445 after another, 154 00:13:00,450 --> 00:13:09,960 the items also come with a particular speed on this moving surface and it can be increased .. like wow, 155 00:13:09,969 --> 00:13:14,260 the items are really coming quickly now... or slowed down. 156 00:13:15,520 --> 00:13:21,830 You can see that if the speed is set for a pace that most people can keep up with, 157 00:13:21,840 --> 00:13:24,900 there will be success in completing the task. 158 00:13:25,250 --> 00:13:31,169 But maybe there would even be a pace that would be too slow for the workers. 159 00:13:31,390 --> 00:13:32,489 For example, 160 00:13:32,500 --> 00:13:34,349 a worker might get bored. 161 00:13:34,539 --> 00:13:37,330 If the items aren't coming fast enough. 162 00:13:38,270 --> 00:13:42,039 a bored worker might have distraction and restlessness. 163 00:13:42,049 --> 00:13:42,059 Oh, 164 00:13:42,070 --> 00:13:42,969 my gosh. 165 00:13:42,979 --> 00:13:44,510 This is so slow. 166 00:13:45,080 --> 00:13:47,090 If the pace were too fast, 167 00:13:47,099 --> 00:13:50,770 the worker wouldn't be able to use all the items coming toward them. 168 00:13:50,780 --> 00:13:52,400 Things would get past them, 169 00:13:52,440 --> 00:13:59,609 things would get missed and only a portion of the items could be manipulated and used for that task. 170 00:14:00,659 --> 00:14:07,349 So the speed and the number of items coming at us needs to be at a just right spot. 171 00:14:08,780 --> 00:14:12,729 My favorite image for this is a classic, 172 00:14:12,739 --> 00:14:26,489 I love Lucy clip from the Chocolate Factory television episode. This episode aired in 1952 and it's considered one of the funniest of the whole comedy series. 173 00:14:26,760 --> 00:14:38,130 I've linked a clip of the Chocolate Factory scene with the conveyor belt in the show notes for those of you who would like to view it or who haven't seen it. 174 00:14:38,140 --> 00:14:51,250 It's a great demonstration of what can go wrong if the speed of the moving belt is too slow or too fast or if too many items are being sequenced on the conveyor belt at once. 175 00:14:54,169 --> 00:14:57,700 Now let's get back to the conveyor belt in our minds. 176 00:14:57,710 --> 00:15:03,270 So if my boss is giving me instructions with multiple details or steps, 177 00:15:03,739 --> 00:15:17,219 it is as if the words or chunks of information are coming toward me from her voice into my mind ... just like the little pieces of chocolate on the conveyor belt 178 00:15:17,229 --> 00:15:18,849 in the comedy clip. 179 00:15:19,080 --> 00:15:24,369 The speed of the conveyor belt is how quickly she's speaking. 180 00:15:24,780 --> 00:15:31,669 And my perception of the speed is impacted by how quickly my brain can process and keep up. 181 00:15:31,700 --> 00:15:35,340 If my brain's conveyor belt is slower. 182 00:15:35,349 --> 00:15:37,200 If I have slower information 183 00:15:37,210 --> 00:15:44,609 processing, the speed that she's giving me information for the conveyor belt may be overwhelming to me. 184 00:15:45,400 --> 00:15:48,559 Or if I have really fast processing, 185 00:15:48,750 --> 00:15:56,630 I may get really bored and distracted while she's talking because there's just not enough that's new coming toward me. 186 00:15:58,960 --> 00:16:01,130 Let's take another example, 187 00:16:01,229 --> 00:16:04,549 this one involving a student in a class. 188 00:16:04,630 --> 00:16:08,919 So a teacher is presenting information to the class. 189 00:16:08,950 --> 00:16:18,429 The student is required to receive the bits of information at the speed they're presenting as if in the conveyor belt analogy. 190 00:16:18,440 --> 00:16:20,369 And here comes new information. 191 00:16:20,380 --> 00:16:34,260 Then the student must hold the information in mind while deciding what parts to write in their notebook or to type in their laptop. 192 00:16:34,429 --> 00:16:38,099 All of this must be done while the teacher is still speaking. 193 00:16:38,489 --> 00:16:40,849 And this is all executive function. 194 00:16:40,859 --> 00:16:43,630 So we'll touch on this in a different episode, 195 00:16:43,640 --> 00:16:49,349 but the student must use another piece of executive function in this task as well ... 196 00:16:49,409 --> 00:16:50,909 prioritization. 197 00:16:51,440 --> 00:16:57,010 So I'm receiving a lot of information on this conveyor belt from the teacher. 198 00:16:57,020 --> 00:17:08,349 But what information is important for my notes and what is not important. To what do I give priority when there's a lot on the conveyor belt. 199 00:17:08,729 --> 00:17:09,668 For example, 200 00:17:09,678 --> 00:17:13,348 it's not necessary to write down every word 201 00:17:13,359 --> 00:17:16,668 the teacher is saying. What the efficient, 202 00:17:16,678 --> 00:17:22,529 just-right thing to do would be to pick out these most important things, 203 00:17:22,538 --> 00:17:23,409 these themes, 204 00:17:23,418 --> 00:17:25,529 these categories, definitions, 205 00:17:25,538 --> 00:17:26,188 dates, 206 00:17:26,239 --> 00:17:30,308 these are the things we need to jot down in our notes. 207 00:17:30,359 --> 00:17:35,668 And our executive function is what helps us with this whole process. 208 00:17:36,069 --> 00:17:36,520 Now, 209 00:17:36,530 --> 00:17:38,319 if it's working well, 210 00:17:38,449 --> 00:17:40,900 the student just does this automatically. 211 00:17:42,060 --> 00:17:45,949 If things are hard in that area of executive function, 212 00:17:46,329 --> 00:17:48,099 the person may feel like, 213 00:17:48,109 --> 00:17:48,540 gosh, 214 00:17:48,550 --> 00:17:48,560 I, 215 00:17:48,569 --> 00:17:49,760 I cannot, 216 00:17:50,729 --> 00:17:51,140 you know... 217 00:17:51,150 --> 00:17:53,500 note taking is very difficult for me. 218 00:17:53,510 --> 00:17:55,229 I just can't keep up. 219 00:17:55,239 --> 00:18:07,400 I can't keep the things in my mind while I'm writing because I either lose them because the teacher is still speaking or I lose what the teacher is now saying. 220 00:18:07,680 --> 00:18:15,839 So it either is something that happens smoothly and automatically or it really becomes a very difficult thing. 221 00:18:17,900 --> 00:18:20,290 Let me give you a social example. 222 00:18:20,579 --> 00:18:27,829 Imagine a person at a social event where a group of people are speaking about a funny experience. 223 00:18:28,300 --> 00:18:35,770 An individual in the group will need to be taking in what multiple people are saying... 224 00:18:35,890 --> 00:18:44,390 So there are multiple conveyor belts and speeds all while holding parts of the conversation in mind. 225 00:18:45,390 --> 00:18:59,500 And this person also then has to think about what they might say or contribute to the conversation and how to time what they're going to contribute and still keep up with the speed of the exchange. 226 00:19:01,930 --> 00:19:11,260 This example also involves those executive function abilities of working memory and speed and sequencing. 227 00:19:13,219 --> 00:19:15,989 Let me give you a life activity example, 228 00:19:16,770 --> 00:19:25,459 driving is a good example of a life activity that requires a person to take in multiple streams of information. 229 00:19:25,469 --> 00:19:26,040 In this case 230 00:19:26,050 --> 00:19:29,300 visual ... at varying speeds. 231 00:19:29,579 --> 00:19:36,520 Oh, this visual information is coming at me as I'm driving through the visual space. 232 00:19:36,920 --> 00:19:59,699 So the individual must first notice incoming visual details, adapt to unpredictable changes in the visual field (like, oh now I have less space in this lane than I did because the car is coming over toward me), and make quick safe decisions about how to respond. 233 00:20:00,310 --> 00:20:06,989 So one individual may feel like this all comes very automatically and at a speed that really works for them, 234 00:20:07,750 --> 00:20:15,699 another individual may feel overwhelmed by the amount of visual information coming at them in such a quick time... 235 00:20:15,839 --> 00:20:21,800 particularly because it's unpredictable and it involves safety issues. 236 00:20:21,810 --> 00:20:26,040 So if I can't keep on top of this visual information, 237 00:20:26,689 --> 00:20:31,400 I really might get in a situation that's really pretty dangerous. 238 00:20:32,479 --> 00:20:37,500 Other people while they're driving may feel concerned because they get bored. 239 00:20:37,729 --> 00:20:51,510 There's just not enough new information in the visual field to keep their mind on the road and they may find their mind wandering in a way that kind of makes them nervous and and leads them feeling like... 240 00:20:51,810 --> 00:20:54,469 they just can't focus very well while they're driving. 241 00:20:56,550 --> 00:21:00,859 What is often the case is that for many on the autism spectrum, 242 00:21:01,079 --> 00:21:18,439 they'll take longer to adjust to driving than their non autistic peers ... most often because they feel like things are really happening quickly and they can feel overwhelmed by the amount the speed and the unpredictability of information on that conveyor belt. 243 00:21:20,229 --> 00:21:22,069 So going back to our episode, 244 00:21:22,079 --> 00:21:25,569 topics of speed, working memory, and sequencing, 245 00:21:25,810 --> 00:21:31,199 we've reviewed that an individual must adapt to the speed of incoming information, 246 00:21:32,060 --> 00:21:35,949 then sequence through the items coming toward them. 247 00:21:36,479 --> 00:21:46,319 Hold enough of the information in mind that is important while then doing something with or responding to the information. 248 00:21:47,660 --> 00:21:57,680 And this is all part of the subcortical frontal pathways of the brain and the ability that globally we call executive function. 249 00:21:59,540 --> 00:22:00,479 So far, 250 00:22:00,489 --> 00:22:05,479 we've emphasized information coming toward us on the conveyor belt. 251 00:22:05,489 --> 00:22:15,589 But we can also think of executive function abilities for the information that we send out on conveyor belts to other people or to the environment. 252 00:22:16,900 --> 00:22:18,229 For example, 253 00:22:18,239 --> 00:22:25,199 how quickly do we produce a product or a response to questions from others? 254 00:22:26,219 --> 00:22:29,920 One person may be quick and efficient with tasks, 255 00:22:30,150 --> 00:22:37,920 but maybe they make a few errors on the way. Another person may finish the task more slowly,  256 00:22:37,930 --> 00:22:39,099 but to them, 257 00:22:39,109 --> 00:22:43,699 accuracy is really important and they notice a lot of detail. 258 00:22:45,390 --> 00:22:51,369 Neither of these executive function styles is inherently better than the other 259 00:22:51,380 --> 00:22:52,390 all the time. 260 00:22:52,630 --> 00:23:01,430 But the person whose executive function is more methodical and detail oriented in producing output may struggle in a job where the boss says, 261 00:23:01,439 --> 00:23:02,089 hey, 262 00:23:02,150 --> 00:23:05,020 the priority on this project is speed. 263 00:23:05,030 --> 00:23:08,130 I need this quickly. And vice versa. 264 00:23:08,140 --> 00:23:17,930 The individual who works quickly and decisively may really struggle at jobs where the smallest detail can make or break a project. 265 00:23:19,800 --> 00:23:27,930 Individuals who make decisions more slowly may show resistance when pressed for an answer or an action. 266 00:23:29,319 --> 00:23:37,910 Other people may almost feel this psychological opposition when they try to encourage the person to decide or to move on. 267 00:23:39,000 --> 00:23:40,500 Let's take an action. 268 00:23:40,510 --> 00:23:42,359 Let's stop thinking about it. 269 00:23:43,430 --> 00:23:52,579 One example could be adult children trying to press their dad to get his roof fixed. If he has executive function 270 00:23:52,589 --> 00:23:56,030 that's significant for being very slow, 271 00:23:56,040 --> 00:23:57,530 methodical... 272 00:23:57,680 --> 00:24:04,130 He may forever be saying things like "I'll think about that" or "I'll know when the time is right," 273 00:24:04,400 --> 00:24:07,439 but there's never any real movement toward action. 274 00:24:07,449 --> 00:24:09,099 There's this stickiness, 275 00:24:09,109 --> 00:24:15,680 the conveyor belt toward decisiveness kind of gets stuck. Again,  276 00:24:15,689 --> 00:24:19,260 this approach to action is not right or wrong, 277 00:24:19,270 --> 00:24:25,800 but it's about whether it works for him in certain instances and against him and others. 278 00:24:26,030 --> 00:24:28,219 And when the roof is falling in, 279 00:24:28,229 --> 00:24:31,219 it's really likely working against him. 280 00:24:32,000 --> 00:24:43,489 Another factor that impacts whether something helps a situation or not is how extreme or inflexible the executive function reaction is in that situation. 281 00:24:44,079 --> 00:24:45,949 So for example, 282 00:24:46,239 --> 00:24:51,810  if we have this situation with the dad and his roof... 284 00:24:51,839 --> 00:25:00,250 a really extreme slow and resistant response to the need for action in that circumstance... 285 00:25:00,260 --> 00:25:00,540 well, 286 00:25:00,550 --> 00:25:01,880 that's creating safety, 287 00:25:01,890 --> 00:25:02,530 health, 288 00:25:02,540 --> 00:25:05,930 financial issues ... that it really could hurt the person. 289 00:25:07,520 --> 00:25:08,349 Ideally, 290 00:25:08,359 --> 00:25:13,770 our brain is supposed to help us have the just right amount of speed, 291 00:25:14,359 --> 00:25:14,650 (you know, 292 00:25:14,660 --> 00:25:16,300 not too quickly, 293 00:25:16,310 --> 00:25:19,439 not too slowly) and sequencing. 294 00:25:19,790 --> 00:25:27,349 I see details that are important but I can let other things go so that I can get to the best outcome. 295 00:25:27,770 --> 00:25:30,199 And when it's important to, you 296 00:25:30,209 --> 00:25:33,510 can adjust to the situation itself. 297 00:25:33,520 --> 00:25:33,900 Wow, 298 00:25:33,910 --> 00:25:37,540 I didn't expect this situation but I can adjust to that. 299 00:25:39,459 --> 00:25:48,989 But sometimes the struggle that a person is having is really that it's hard to get to that just right spot for ... for anything, 300 00:25:49,000 --> 00:25:51,880 whether it's speed or executive function or, 301 00:25:51,890 --> 00:26:00,180 or anything else in life ... rather than sometimes swinging to that too much extreme. 302 00:26:02,329 --> 00:26:13,569 One more example of the sequencing of output could be seen when multiple smaller actions are needed to complete a larger task. 303 00:26:14,099 --> 00:26:20,699 So a classic example of this would be the parental request that their child clean his room. 304 00:26:21,680 --> 00:26:32,449 So the child has to think through all of the pieces of action that will need to be engaged with in order to get this finished product. 305 00:26:32,849 --> 00:26:37,989 It's almost like saying what are all the pieces I need to put on this conveyor belt, 306 00:26:38,020 --> 00:26:46,030 all the pieces that I need to to bring together for the whole action of having a clean room or the whole outcome. 307 00:26:47,310 --> 00:26:48,500 There's a first step, 308 00:26:48,510 --> 00:26:49,400 a second step, 309 00:26:49,410 --> 00:27:01,109 a third step ... all on the conveyor belt until a finished product is reached. Some ways in which this executive function task can get stuck would include... 310 00:27:01,400 --> 00:27:01,930 "Wow, 311 00:27:01,939 --> 00:27:06,599 there are so many actions or pieces to the task. 312 00:27:07,040 --> 00:27:10,829  I just don't know where to start. 313 00:27:11,949 --> 00:27:12,930 I'm stuck. 314 00:27:12,939 --> 00:27:16,599 I'm overwhelmed by the amount of possibility. 315 00:27:16,880 --> 00:27:23,709 I can't get my direction to navigate the task even though I could do all of these little pieces, 316 00:27:23,760 --> 00:27:25,310 where should I start?" 317 00:27:25,930 --> 00:27:28,400 And this is often the situation. 318 00:27:29,089 --> 00:27:31,959 And the parent may say, 319 00:27:31,969 --> 00:27:32,170 "Hey, 320 00:27:32,180 --> 00:27:33,369 start wherever you want, 321 00:27:33,380 --> 00:27:34,449 it doesn't matter." 322 00:27:35,349 --> 00:27:41,739 But that's not likely to help the child who actually needs someone to sequence the task with them. 323 00:27:42,089 --> 00:27:43,810 Tell me where to start. 324 00:27:43,829 --> 00:27:46,319 How can I get going with this task? 325 00:27:46,709 --> 00:27:49,630 And then after I do the task, 326 00:27:50,239 --> 00:27:51,619 ... the first task, 328 00:27:51,849 --> 00:27:53,739 what's the second task I should do? 329 00:27:53,750 --> 00:27:59,199 How should I string things along without getting overwhelmed or stuck or lost? 330 00:28:00,739 --> 00:28:11,000 The child knows how to do each little part of the task but doesn't have the sequencing ability to navigate this larger task without assistance. 331 00:28:11,010 --> 00:28:22,510 And so the parent who realizes this might take a picture representing each smaller task ... like a photo of clothes in the laundry basket, 332 00:28:23,010 --> 00:28:25,750 a photo of books on the bookshelf, 333 00:28:25,760 --> 00:28:34,650 a photo of the bed made ... whatever the five or seven steps to having a clean room might be. 334 00:28:34,920 --> 00:28:39,849 You can put these photos up in a place where the child can see them. 335 00:28:41,369 --> 00:28:45,739 The child then can look at the photos independently and see... 336 00:28:45,750 --> 00:28:50,199 Oh the first photo is clothes in the the clothes hamper. 337 00:28:50,209 --> 00:28:56,800 So I'm gonna do that first...  and sometimes the child likes to take the photo down when the task is done. 338 00:28:57,099 --> 00:28:58,959 And so "I know that's done." 339 00:29:01,010 --> 00:29:10,609 That's just one way to help teach an executive function skill for someone who is overwhelmed and trying to do that independently. 340 00:29:13,040 --> 00:29:21,750 Knowing that the full anatomical maturity of executive function isn't complete until the age of 20 or 21 or so. 341 00:29:21,959 --> 00:29:29,050 The parent realizes that part of their role is to help the child learn strategies for approaching tasks 342 00:29:29,060 --> 00:29:37,170 requiring executive function ... and to assist in areas where the child is still really developing that ability. 343 00:29:38,719 --> 00:29:39,479 Additionally, 344 00:29:39,489 --> 00:29:42,089 as we noted in the previous episode, 345 00:29:42,170 --> 00:29:47,069 everyone will have individual strengths and struggles in executive function. 346 00:29:47,880 --> 00:29:52,810 If this is a child who grows up and continues to have a weakness 347 00:29:52,819 --> 00:29:56,369 organizing a sequence to complete a task, 348 00:29:56,410 --> 00:30:02,300 they can really benefit from a strategy approach to give their brain some assistance. 349 00:30:02,780 --> 00:30:04,729 So their strategy might be... 350 00:30:04,739 --> 00:30:09,880 What if I think about this task as seven smaller tasks? 351 00:30:09,890 --> 00:30:10,979 What would those be? 352 00:30:12,170 --> 00:30:24,239 I would invite you to notice tasks in your everyday life that are easy or difficult for you and consider if they have executive function components like speed, 353 00:30:24,349 --> 00:30:26,500 working memory, or sequencing. 354 00:30:27,219 --> 00:30:29,000 Notice what's easy for you, 355 00:30:29,010 --> 00:30:31,890 what's difficult for you in these situations. 356 00:30:32,449 --> 00:30:40,930 This increased self-awareness can be a first step toward getting the best outcome in a variety of situations. 357 00:30:41,349 --> 00:30:48,170 You may realize "my nervous system default is to process information slowly. 358 00:30:48,719 --> 00:30:54,170 But this new job that I have requires speed in these areas. 359 00:30:54,380 --> 00:30:56,650 And how can I get a better outcome?" 360 00:30:57,750 --> 00:30:58,130 Well, 361 00:30:58,140 --> 00:31:03,170 the basic neurology of speed that your nervous system is set toward, 362 00:31:03,410 --> 00:31:03,890 you know, 363 00:31:03,900 --> 00:31:06,890 you may not be able to adjust that piece. 364 00:31:06,959 --> 00:31:16,819 But perhaps you could focus on strategies to reduce anything that would take away from the speed you're capable of neurologically. 365 00:31:17,160 --> 00:31:20,589 So perhaps you want to reduce distractions, 366 00:31:20,920 --> 00:31:32,089 maybe ask someone for input about what the most important thing to focus on is and really make sure that you're accountable to someone who can see the big picture a little better. 367 00:31:33,599 --> 00:31:36,140 As I noted in the previous episode, 368 00:31:36,189 --> 00:31:43,150 I like the book series Smart but Scattered when it comes to strategies for executive function, 369 00:31:43,160 --> 00:31:47,949 but you can choose whatever resources best fit your needs. 370 00:31:48,119 --> 00:31:52,010 And if you want to dive into more about executive function, 371 00:31:52,170 --> 00:31:58,609 learn about more strategies for success in areas that are causing you difficulty... by all means, 372 00:31:58,619 --> 00:32:01,969 reach out and find things that work well for you. 373 00:32:04,079 --> 00:32:08,390 I wanna thank you for joining me to learn about the executive function 374 00:32:08,400 --> 00:32:12,560 sub features of speed, sequencing, and working memory. 375 00:32:12,849 --> 00:32:21,650 And I hope it increases your understanding of what makes you tick. We'll be continuing our series on executive function next time. 376 00:32:21,660 --> 00:32:24,810 So I invite you to join me for that third episode.        

Do you understand what Executive Function (EF) refers to and why it is important? If you have EF difficulties, have you been diagnosed with ADHD? Do you wonder if you have a diagnosis of autism or if you should have a dual diagnosis of autism and ADHD? Dr. Regan breaks down the concepts and shares about the relationship between EF, ADHD, and autism.    Executive Function Book Series by Dawson and Guare: Smart But Scattered (children's version) Smart But Scattered (Teen version) Smart But Scattered (adult version)   Dr. Regan's Master Class for Clinicians: Zur Institute: Master Class   Dr. Regan's Resources Book: Understanding Autism in Adults and Aging Adults, 2nd ed Audiobook Book: Understanding Autistic Behaviors Autism in the Adult website homepage Website Resources for Clinicians   Read the transcript:   1 00:00:07,670 --> 00:00:08,560 Hi there. 2 00:00:08,569 --> 00:00:13,960 This is Doctor Regan joining you for an episode of Autism in the Adult podcast. 3 00:00:14,850 --> 00:00:16,670 I'm a neuropsychologist, 4 00:00:16,680 --> 00:00:24,350 the founder and director of an autism diagnostic clinic in Central Illinois and the parent of a teen on the spectrum. 5 00:00:25,180 --> 00:00:25,899 Today, 6 00:00:25,909 --> 00:00:31,610 you are joining me for the first episode in a new series about executive function. 7 00:00:31,989 --> 00:00:36,509 And I'm really excited for the series since announcing the topic. 8 00:00:36,520 --> 00:00:38,509 At the end of our last episode, 9 00:00:38,520 --> 00:00:45,709 I've received lots of emails from interested listeners before we dive into today's episode. 10 00:00:45,720 --> 00:00:45,990 Though, 11 00:00:46,000 --> 00:00:50,490 I wanna give a shout out to the clinicians and professionals who may be listening. 12 00:00:50,799 --> 00:01:00,610 I'm currently developing a master class with the continuing education platform called Zur Institute. 13 00:01:01,020 --> 00:01:04,010 This offering is unique for several reasons. 14 00:01:04,019 --> 00:01:05,449 One is the format, 15 00:01:06,050 --> 00:01:09,550 there will be four 2-hour webinars, 16 00:01:09,559 --> 00:01:11,949 one in each of September, 17 00:01:12,209 --> 00:01:13,099 October, 18 00:01:13,110 --> 00:01:16,180 November and December of 2023. 19 00:01:16,809 --> 00:01:23,629 And the first hour will be education while the second full hour will be reserved for discussion, 20 00:01:23,639 --> 00:01:32,519 question and answer and interaction with you about clinical questions and practice issues related to the topic for that day. 21 00:01:32,889 --> 00:01:44,419 Another unique feature of this offering will be the focus on advanced topics. So click on the link in the show notes to read more about the topics and how to sign up. 22 00:01:45,330 --> 00:01:49,569 If you are a clinician wanting beginner or intermediate courses, 23 00:01:49,599 --> 00:01:54,440 check out my other offerings on Zur or at my website, 24 00:01:54,449 --> 00:01:57,819 which is also linked through the show notes. 25 00:01:58,440 --> 00:01:59,040 All right, 26 00:01:59,050 --> 00:02:01,580 let's talk about executive function. 27 00:02:02,449 --> 00:02:07,800 I'll warn you that today's episode will require some executive function to get through. 28 00:02:08,350 --> 00:02:14,740 And I've spent a lot of time trying to make sure that I'm linking all of the themes together. 29 00:02:15,179 --> 00:02:16,649 So with that in mind, 30 00:02:16,800 --> 00:02:22,440 I want to start off with just a general definition of executive function. 31 00:02:24,440 --> 00:02:26,500 Later in our talks, 32 00:02:26,509 --> 00:02:34,229 we will cover a more precise and descriptive definition including sub elements and what we might call those. 33 00:02:35,020 --> 00:02:45,990 So executive function refers to a set of brain based abilities related to the functioning of the pathways connecting the center and the front of the brain. 34 00:02:46,679 --> 00:02:48,710 And the reason for the name, 35 00:02:48,720 --> 00:02:59,850 executive functioning is that executive is defined as having the power to put plans and actions into effect. 36 00:03:00,860 --> 00:03:04,710 So a CEO for example, 37 00:03:05,240 --> 00:03:14,669 is the chief executive officer of a business company and is in charge of directing the tiers of the company, 38 00:03:14,679 --> 00:03:16,250 the regional officers, 39 00:03:16,259 --> 00:03:17,059 managers, 40 00:03:17,070 --> 00:03:18,270 direct workers, 41 00:03:18,490 --> 00:03:24,440 directing all the pieces to work together toward the same goal. 42 00:03:24,970 --> 00:03:33,339 So these pathways of the brain help the parts of the brain work together to achieve a goal. 43 00:03:34,259 --> 00:03:38,360 Another image that I like is the symphony conductor, 44 00:03:38,899 --> 00:03:42,190 directing all the instruments in the orchestra, 45 00:03:42,199 --> 00:03:46,130 even if all the instruments are performing perfectly, 46 00:03:46,240 --> 00:03:48,300 if there's no conductor, 47 00:03:48,679 --> 00:03:56,179 there's no unified sound with melody and movement and this synchrony of sound. 48 00:03:56,399 --> 00:04:04,309 So the sounds don't come together to create a moving and meaningful piece of music without the conductor. 49 00:04:05,039 --> 00:04:09,100 So executive function is like the symphony conductor, 50 00:04:09,490 --> 00:04:14,199 it should bring all of the working parts of the brain together to perform. 51 00:04:14,210 --> 00:04:17,049 So that something meaningful happens. 52 00:04:18,998 --> 00:04:19,688 As I said, 53 00:04:19,699 --> 00:04:22,848 executive function is a set of brain skills, 54 00:04:22,859 --> 00:04:24,408 it's not one skill. 55 00:04:25,160 --> 00:04:29,929 And as we understand what the center of the brain, 56 00:04:30,109 --> 00:04:37,130 the subcortical areas of the brain and the connections through the center with the front of the brain, 57 00:04:37,140 --> 00:04:38,350 the frontal lobes. 58 00:04:38,809 --> 00:04:42,209 When we understand what these areas are in charge of, 59 00:04:42,220 --> 00:04:46,820 we refer to those set of abilities as executive function. 60 00:04:46,829 --> 00:04:53,149 So these executive function abilities hang together anatomically in the brain. 61 00:04:53,540 --> 00:04:56,640 So through that subcortical frontal system, 62 00:04:57,339 --> 00:05:04,059 so the number one point is that executive function refers to a series of skills, 63 00:05:04,070 --> 00:05:05,519 not one skill. 64 00:05:05,850 --> 00:05:10,190 And these skills are linked with anatomy, 65 00:05:10,200 --> 00:05:13,290 with the subcortical frontal systems of the brain. 66 00:05:13,609 --> 00:05:21,279 And the skills help the brain produce a meaningful synchronous um behavior or, 67 00:05:21,290 --> 00:05:22,489 or product. 68 00:05:24,070 --> 00:05:24,470 Now, 69 00:05:24,480 --> 00:05:32,950 let's talk about the diagnosis of AD D and A DH D and just for simplicity's sake, 70 00:05:32,959 --> 00:05:33,920 from now on, 71 00:05:33,929 --> 00:05:39,920 I'll really just refer to these as AD D but I'm referring to both diagnoses. 72 00:05:41,269 --> 00:05:45,839 This diagnosis was introduced in the diagnostic manual, 73 00:05:45,850 --> 00:05:57,970 the DSM - III in 1980 it was important because it described a developmental neurologic condition of executive function. 74 00:05:58,950 --> 00:06:02,820 So executive function was not a new concept, 75 00:06:02,989 --> 00:06:10,739 but the diagnosis of ADD was the one that captured this developmental piece. 76 00:06:11,190 --> 00:06:22,299 So here we have a diagnosis then that we can use to describe a difficulty that an individual has based on their developmental wiring. 77 00:06:22,309 --> 00:06:26,200 The way that the brain system has developed, 78 00:06:26,239 --> 00:06:38,600 the way they're wired in the executive function areas of the brain don't finish their anatomic development until about the age of 20 or 21. 79 00:06:38,980 --> 00:06:39,440 So, 80 00:06:39,450 --> 00:06:40,799 anatomically, 81 00:06:40,989 --> 00:06:45,730 executive function is still developing until about that age. 82 00:06:47,119 --> 00:07:02,500 So the number two point is that ADD was a notable addition to the diagnostic manual in 1980 because it represents a diagnosis for executive function difficulties that are developmental in nature. 83 00:07:04,059 --> 00:07:05,190 Now, 84 00:07:05,399 --> 00:07:19,910 I want to talk about the relationship between executive function and AD D executive function is not specific to ADD or ADHD. 85 00:07:20,690 --> 00:07:23,239 So the difficulties in that domain, 86 00:07:23,540 --> 00:07:26,559 they're not specific to this diagnosis. 87 00:07:26,570 --> 00:07:36,290 We're discussing executive function is one of the most sensitive brain functions to any kind of stress, 88 00:07:36,299 --> 00:07:39,619 whether that is physical or psychological. 89 00:07:40,049 --> 00:07:45,429 One of the first things to show difficulty is going to be executive function. 90 00:07:47,630 --> 00:07:56,119 It's often the first thing to become difficult and the last thing to resolve or heal after some type of challenge. 91 00:07:57,390 --> 00:07:58,829 For example, 92 00:07:59,089 --> 00:08:02,600 if an 80 year old has a bladder infection. 93 00:08:02,609 --> 00:08:11,040 What's probably the most sensitive cognitive function that's going to be disrupted first ... executive function. 94 00:08:11,739 --> 00:08:25,959 And if someone is recovering from a traumatic brain injury and they've gone through rehab and it's two or three months after ... what's probably the residual problem that's still kind of healing up. 95 00:08:25,970 --> 00:08:26,299 Well, 96 00:08:26,309 --> 00:08:28,679 that would be executive function as well. 97 00:08:31,179 --> 00:08:39,059 So there may be developmental differences in executive function and that's what we discuss 98 00:08:39,070 --> 00:08:41,969 when we talk about the diagnosis of ADD, 99 00:08:43,000 --> 00:08:47,960 there can also be acquired differences in executive function. 100 00:08:48,409 --> 00:08:51,690 This would include differences after, 101 00:08:51,700 --> 00:08:52,450 as we said, 102 00:08:52,460 --> 00:08:53,869 a traumatic brain injury, 103 00:08:53,880 --> 00:08:58,830 a stroke, within the context of a dementia... acquired 104 00:08:58,840 --> 00:09:02,070 meaning that this is not developmental. 105 00:09:02,080 --> 00:09:06,469 It's something that has occurred in the course of the life span. 106 00:09:08,809 --> 00:09:10,039 Executive function, 107 00:09:10,049 --> 00:09:15,609 difficulties can occur with acute or chronic medical problems. 108 00:09:15,619 --> 00:09:19,820 So an acute medical issue would be like an infection. 109 00:09:19,830 --> 00:09:20,599 For example, 110 00:09:20,609 --> 00:09:23,340 this is something that comes and then it goes, 111 00:09:23,609 --> 00:09:24,500 it's acute, 112 00:09:24,510 --> 00:09:25,460 it's new, 113 00:09:25,619 --> 00:09:35,299 it kind of can hit kind of hard and then heal up and go. Or executive function can be disrupted due to chronic medical problems. 114 00:09:35,330 --> 00:09:37,510 So someone with kidney failure, 115 00:09:37,520 --> 00:09:38,469 for example, 116 00:09:38,479 --> 00:09:40,090 who's on dialysis, 117 00:09:40,289 --> 00:09:45,484 what's the most likely thing they're going to have some difficulties with in the cognitive domain. 118 00:09:45,585 --> 00:09:45,955 Well, 119 00:09:45,965 --> 00:09:47,765 that would be executive function, 120 00:09:47,914 --> 00:09:52,255 someone with sugar fluctuations in the context of diabetes, 121 00:09:52,284 --> 00:09:56,525 someone with metabolic differences like their sodium is too low. 122 00:09:56,554 --> 00:10:02,385 These can also cause a disruption in someone's executive function system, 123 00:10:04,080 --> 00:10:10,169 even differences in the load that the person is carrying with regard to stress, 124 00:10:10,179 --> 00:10:11,530 emotional pain, 125 00:10:11,539 --> 00:10:12,330 trauma, 126 00:10:12,340 --> 00:10:13,679 lack of sleep, 127 00:10:13,710 --> 00:10:17,429 and even just having too much on our schedule. 128 00:10:17,780 --> 00:10:25,729 These examples of things don't change the anatomy of the brain and how the parts of the brain are working. 129 00:10:25,739 --> 00:10:32,450 But it really does interfere with our access to using our full capacity, 130 00:10:32,460 --> 00:10:37,109 our full anatomic, biologic capacity for executive function. 131 00:10:37,530 --> 00:10:37,880 So, 132 00:10:37,890 --> 00:10:39,359 if we've had trauma, 133 00:10:39,479 --> 00:10:39,830 you know, 134 00:10:39,840 --> 00:10:43,409 our brain may just go offline if we dissociate. 135 00:10:43,659 --> 00:10:50,400 And even though our anatomy is working well to produce this executive function, 136 00:10:50,750 --> 00:10:55,419 we may experience a psychological process that takes us offline. 137 00:10:56,520 --> 00:10:57,299 In addition, 138 00:10:57,309 --> 00:10:59,390 even with normal aging, 139 00:10:59,469 --> 00:11:02,750 what's the first thing to start to show difficulty? 140 00:11:02,830 --> 00:11:03,270 Yes, 141 00:11:03,280 --> 00:11:04,830 it's executive function. 142 00:11:05,200 --> 00:11:08,419 And if you are aging really well, 143 00:11:08,440 --> 00:11:08,900 you're, 144 00:11:08,909 --> 00:11:10,820 you're really aging nicely. 145 00:11:10,900 --> 00:11:13,380 You don't have any additional medical issues, 146 00:11:13,390 --> 00:11:14,719 you haven't had an injury. 147 00:11:15,059 --> 00:11:20,659 The first thing you're gonna start to notice is some problem in the area of executive function. 148 00:11:20,849 --> 00:11:26,770 That's just the aging process and how it impacts that subcortical frontal system. 149 00:11:27,210 --> 00:11:37,190 So you may walk into a room and you can't remember why, or you have this tip of the tongue phenomenon where you know what you wanna say 150 00:11:37,200 --> 00:11:38,549 but you can't get it out. 151 00:11:38,570 --> 00:11:40,049 That's executive function. 152 00:11:40,619 --> 00:11:45,500 You may have to think more slowly or take in less information at a time. 153 00:11:47,140 --> 00:11:53,719 So all individuals are likely to experience executive function difficulty in these contexts. 154 00:11:54,270 --> 00:11:56,609 So consider this comparison, 155 00:11:57,869 --> 00:12:01,799 executive function is similar to fatigue, 156 00:12:01,809 --> 00:12:02,739 for example, 157 00:12:02,750 --> 00:12:10,200 in that it's a nonspecific feature of many different kinds of conditions. 158 00:12:10,849 --> 00:12:12,820 So if someone has fatigue, 159 00:12:13,409 --> 00:12:18,700 there would be hundreds... thousands of conditions that could produce fatigue, 160 00:12:19,020 --> 00:12:22,039 anything from lack of sleep to infection, 161 00:12:22,109 --> 00:12:23,799 autoimmune conditions. 162 00:12:23,809 --> 00:12:25,440 And so many more things. 163 00:12:26,419 --> 00:12:27,340 Similarly, 164 00:12:27,349 --> 00:12:34,140 executive function difficulty can be caused by so so many conditions and situations, 165 00:12:34,150 --> 00:12:34,880 trauma, 166 00:12:34,890 --> 00:12:35,520 aging, 167 00:12:35,530 --> 00:12:36,320 ADD, 168 00:12:36,330 --> 00:12:37,780 autoimmune conditions, 169 00:12:37,789 --> 00:12:39,669 delirium, autism, and many, 170 00:12:39,679 --> 00:12:40,429 many more. 171 00:12:40,799 --> 00:12:49,750 So the third point we've really focused on here so far is that executive function is not specific to ADD. 172 00:12:50,080 --> 00:12:55,119 So many many things can trigger this executive function problem. 173 00:12:57,539 --> 00:12:58,150 Therefore, 174 00:12:58,159 --> 00:13:01,859 if someone presents with executive function difficulty -- 175 00:13:02,200 --> 00:13:05,030 so I'm having a hard time paying attention, 176 00:13:05,039 --> 00:13:07,700 I just can't take in information very well. 177 00:13:07,729 --> 00:13:10,349 I can't organize myself well -- 178 00:13:10,359 --> 00:13:20,570 the clinician should consider differentials in the diagnostic process because so many things can present with those features. 179 00:13:20,840 --> 00:13:24,369 There should be this process of taking into account. 180 00:13:24,630 --> 00:13:26,590 What is this person's age? 181 00:13:26,599 --> 00:13:28,750 What is their recent life experience? 182 00:13:28,760 --> 00:13:30,679 What are their medical issues? 183 00:13:30,690 --> 00:13:33,390 When did the executive function issue start? 184 00:13:34,210 --> 00:13:39,469 But executive function difficulty does not automatically mean ADD. 185 00:13:39,479 --> 00:13:41,549 It does not equal ADD, 186 00:13:41,559 --> 00:13:43,739 it's not equivalent to ADD. 187 00:13:45,469 --> 00:14:00,440 So we would consider a handful of things that could cause executive function problems in this person, and then would perform an evaluation to see what the most likely contributors are in this case. 188 00:14:01,289 --> 00:14:04,830 So let's go over our first three points. 189 00:14:05,109 --> 00:14:09,489 Executive function refers to a series of skills, 190 00:14:09,500 --> 00:14:16,190 not one skill and these skills are linked anatomically within the same pathways -- 191 00:14:16,200 --> 00:14:27,729 these subcortical frontal system pathways -- and they also work together to provide some meaningful and organized output from the brain. 192 00:14:29,229 --> 00:14:47,950 The second point is that ADD was added to the diagnostic manual in 1980 to describe developmental executive function differences, and that was really helpful to have a diagnosis for developmental differences in executive function. 193 00:14:49,669 --> 00:15:00,539 The third point is that executive function is not specific to ADD -- many many things can trigger executive function difficulty. 194 00:15:01,239 --> 00:15:10,909 And so we would never want to hear executive function difficulty and then translate that automatically into ADD. 195 00:15:15,289 --> 00:15:20,659 So we talked about how executive function refers to a series of skills. 196 00:15:21,270 --> 00:15:28,479 There's not a unanimous consensus about what constitutes all these subparts, 197 00:15:28,489 --> 00:15:30,979 how to number them and what to call them. 198 00:15:31,090 --> 00:15:37,080 But many conceptualizations may refer to about 12 to 15 components. 199 00:15:37,090 --> 00:15:38,039 Give or take. 200 00:15:39,330 --> 00:15:44,460 These often include things like organization, sequencing, 201 00:15:44,469 --> 00:15:46,020 processing speed, 202 00:15:46,030 --> 00:15:48,260 prioritizing, planning, 203 00:15:48,270 --> 00:15:49,960 task initiation, 204 00:15:50,070 --> 00:15:52,130 sustained attention, goal 205 00:15:52,140 --> 00:15:53,510 directed persistence, 206 00:15:53,520 --> 00:15:54,859 impulse control, 207 00:15:54,869 --> 00:15:56,099 time management, 208 00:15:56,109 --> 00:15:57,640 generation of ideas, 209 00:15:57,650 --> 00:15:58,739 working memory, 210 00:15:58,750 --> 00:16:01,880 flexibility and emotional regulation. 211 00:16:03,119 --> 00:16:06,030 So it's not important for you to know what those mean. 212 00:16:06,250 --> 00:16:14,309 But I want you to get the sense that there are these multiple components and we'll look at each of these later in our series. 213 00:16:14,320 --> 00:16:15,559 But for now, 214 00:16:15,570 --> 00:16:16,150 wow, 215 00:16:16,159 --> 00:16:19,669 executive function is a broad category. 216 00:16:22,250 --> 00:16:28,020 ADD, which as we said describes a condition of developmental 217 00:16:28,030 --> 00:16:36,700 executive function difficulty, includes four areas as I would describe them. 218 00:16:36,710 --> 00:16:38,880 So someone may say, 219 00:16:38,890 --> 00:16:38,909 oh, 220 00:16:38,919 --> 00:16:40,869 I think it's more like five. 221 00:16:40,940 --> 00:16:42,520 so it doesn't matter, 222 00:16:42,530 --> 00:16:44,270 but it's a small subset. 223 00:16:44,280 --> 00:16:45,679 We've got attention, 224 00:16:45,909 --> 00:16:47,119 organization, 225 00:16:47,130 --> 00:16:47,940 goal directed 226 00:16:47,950 --> 00:16:50,109 persistence, and impulse control. 227 00:16:51,869 --> 00:17:09,130 The diagnostic criteria for ADD only describe four areas of executive function even though our current understanding is that there are probably more like 12 to 15 components. 228 00:17:10,900 --> 00:17:28,949 So you can see that someone could have significant difficulty with executive function developmentally and not meet the criteria for ADD because these four specific areas included may not be the ones that are causing this problem. 229 00:17:29,290 --> 00:17:31,949 This person's individual difficulty... 230 00:17:33,109 --> 00:17:36,160 I also want you to know that every single person, 231 00:17:37,189 --> 00:17:40,119 regardless of developmental neurology, 232 00:17:40,130 --> 00:17:41,920 health background, 233 00:17:42,130 --> 00:17:46,449 all humans will have a pattern of executive function, 234 00:17:46,630 --> 00:17:48,839 strengths and weaknesses. 235 00:17:49,040 --> 00:17:51,599 That's the normal way of our neurology. 236 00:17:52,329 --> 00:17:56,780 So out of those 12 to 15 subsets of skills, 237 00:17:56,959 --> 00:18:11,640 you can kind of imagine this graph across the all of these different points and sometimes we'll have ups and downs there that can help inform us what we struggle with and what we're really finding easy. 238 00:18:12,449 --> 00:18:18,640 So a person who's really good in the areas of generating ideas and flexibility, 239 00:18:18,650 --> 00:18:21,339 this person might be called creative. 240 00:18:21,349 --> 00:18:22,920 All these ideas, 241 00:18:22,930 --> 00:18:24,140 they're very flexible, 242 00:18:24,150 --> 00:18:25,579 they go from here to there, 243 00:18:25,839 --> 00:18:29,609 but they may struggle with other areas of executive function, 244 00:18:30,040 --> 00:18:31,959 they may be impulsive, 245 00:18:32,000 --> 00:18:35,979 have difficulty with time management, organization... 246 00:18:36,180 --> 00:18:41,780 So everybody has their own pattern with an executive function. 247 00:18:43,069 --> 00:18:45,640 So let's go back here. 248 00:18:45,650 --> 00:18:52,219 We are setting up a discussion of the relationship between executive function and ADD. 249 00:18:52,819 --> 00:19:01,339 And one of the difficulties we currently have is that our understanding of executive function has evolved since 1980. 250 00:19:01,780 --> 00:19:12,500 But we have a diagnosis that covers only a small subset of how we currently conceptualize executive function. 251 00:19:13,349 --> 00:19:25,880 This creates difficulty in that someone may clearly have developmental executive function problems but not fit into the box of the ADD diagnostic criteria. 252 00:19:28,280 --> 00:19:29,010 Now, 253 00:19:29,849 --> 00:19:33,420 let's compare ADD and autism. 254 00:19:35,489 --> 00:19:43,300 Everyone on the autism spectrum will have executive function difficulty in some form or pattern. 255 00:19:45,040 --> 00:19:48,290 That's because of the neurology of autism. 256 00:19:50,880 --> 00:19:57,329 The term executive function is not specifically used in the autism criteria, 257 00:19:57,359 --> 00:20:09,849 but many of the criteria describe behavioral patterns that tap into that neurology and that reflect difficulty in executive function and that subcortical frontal system. 258 00:20:11,849 --> 00:20:21,040 So autism has this executive function component plus many nonexecutive function elements as well. 259 00:20:22,930 --> 00:20:28,709 So ADD is a diagnosis of four or so elements of executive function. 260 00:20:29,219 --> 00:20:37,819 Autism is a diagnosis that includes elements of executive function and elements outside of executive function. 261 00:20:39,469 --> 00:20:52,160 The diagnostic manual indicates that the diagnosis of ADD cannot be made if another diagnosis better accounts for the client's whole presentation. 262 00:20:54,359 --> 00:21:15,699 The diagnostic manual says about autism that ADD can also be in diagnosed along with autism when attentional difficulties or hyperactivity exceeds that typically seen in autism. 263 00:21:19,569 --> 00:21:21,280 So let's regroup. 264 00:21:21,969 --> 00:21:23,310 Executive function, 265 00:21:23,319 --> 00:21:28,189 difficulties occur secondary to so many developmental, 266 00:21:28,199 --> 00:21:30,339 physical and psychological states. 267 00:21:30,859 --> 00:21:39,660 And ADD and autism are two developmental diagnoses that include executive function difficulty. 268 00:21:40,829 --> 00:21:49,989 ADD includes about four elements of the 12 to 15 sub elements of executive function that we generally think of. 269 00:21:50,359 --> 00:22:02,369 And autism includes some pattern of executive function difficulty across elements and also has nonexecutive function 270 00:22:02,680 --> 00:22:04,239 parts to the criteria. 271 00:22:06,560 --> 00:22:18,890 what should happen is that an individual presenting with developmental executive function difficulty would see a clinician who develops an appropriate differential, 272 00:22:19,770 --> 00:22:24,810 that is the person has developmental executive function difficulty, 273 00:22:24,839 --> 00:22:27,569 but that's not specific to ADD. 274 00:22:27,579 --> 00:22:33,810 So let's consider other developmental conditions like autism. 275 00:22:33,819 --> 00:22:40,819 And also let's consider other relevant information like the trauma history, 276 00:22:40,829 --> 00:22:42,640 medical conditions, 277 00:22:42,670 --> 00:22:44,229 intellectual abilities, 278 00:22:44,239 --> 00:22:45,839 learning disabilities, 279 00:22:45,849 --> 00:22:47,810 language processing ability. 280 00:22:48,040 --> 00:22:53,819 And let's figure out what the basis of this executive function problem is. 281 00:22:56,089 --> 00:23:02,239 But what actually happens is that a teacher, doctor, or clinician says, 282 00:23:02,359 --> 00:23:02,979 oh, 283 00:23:02,989 --> 00:23:06,750 this person has developmental executive function difficulty. 284 00:23:07,010 --> 00:23:07,900 Therefore, 285 00:23:07,910 --> 00:23:10,280 we're going to diagnose them with ADD. 286 00:23:11,709 --> 00:23:13,319 Then years later, 287 00:23:13,569 --> 00:23:17,390 they come to see a professional who does an evaluation and says, 288 00:23:17,400 --> 00:23:18,050 well, 289 00:23:18,469 --> 00:23:21,589 this person does have executive function problems, 290 00:23:21,599 --> 00:23:32,270 but the root of their attention problem is that they have an intellectual disability and nobody's ever checked or they can't process language well. 291 00:23:32,280 --> 00:23:33,239 And so of course, 292 00:23:33,250 --> 00:23:42,689 they can't attend in the classroom... or they have a learning disability so they can't attend if they can't understand what they're learning. 293 00:23:44,040 --> 00:23:52,050 Some of these individuals have executive function difficulty because they've been on the autism spectrum all along. 294 00:23:52,060 --> 00:23:56,359 But autism was never included in the differential process. 295 00:23:56,890 --> 00:24:00,250 So they've never been assessed for autism. 296 00:24:01,310 --> 00:24:11,819 It's kind of like hearing that someone has difficulty with fatigue and then assigning a diagnosis of chronic fatigue syndrome without thinking through any differential. 297 00:24:12,660 --> 00:24:12,880 Now, 298 00:24:12,890 --> 00:24:18,630 not everyone with fatigue is best served by a diagnosis of chronic fatigue syndrome. 299 00:24:18,829 --> 00:24:40,849 And not everyone with executive function difficulty is best described by a diagnosis of ADD. ADD should be given if another diagnosis or condition does not more fully explain the full constellation of characteristics. 300 00:24:42,290 --> 00:24:51,180 So even if the individual meets all the criteria for difficulty in those four subs skills, 301 00:24:52,859 --> 00:25:04,869 the diagnosis is not made if this executive function difficulty is better explained by autism or intellectual disability or learning disability, 302 00:25:04,880 --> 00:25:05,550 et cetera. 303 00:25:05,630 --> 00:25:11,089 So the question in the case of ADD diagnosis shouldn't just be, 304 00:25:11,099 --> 00:25:15,319 are the criteria met ... but are the criteria met 305 00:25:15,329 --> 00:25:29,270 and is this the diagnosis that best explains the whole presentation for this student or client or patient? In autism, 306 00:25:29,280 --> 00:25:41,550 executive function difficulties for one individual may include maybe two of those four subs skills that are in our definition of ADD and maybe three other executive function skills. 307 00:25:42,910 --> 00:25:44,500 They still have autism, 308 00:25:44,619 --> 00:25:48,989 they still have executive function difficulty as we would expect. 309 00:25:49,260 --> 00:25:54,510 But perhaps they're less likely to have a pairing of an ADD diagnosis. 310 00:25:56,579 --> 00:26:06,150 Another person on the autism spectrum may have all four of those difficulties in the ADD category and maybe a couple that aren't. 311 00:26:06,500 --> 00:26:12,170 And so they get these two diagnoses autism and ADD. 312 00:26:14,069 --> 00:26:14,900 However, 313 00:26:14,910 --> 00:26:22,260 if the executive function difficulty is not excessive for what we expect to see in autism, 314 00:26:22,640 --> 00:26:24,650 they shouldn't have that diagnosis. 315 00:26:24,660 --> 00:26:25,869 That second one, 316 00:26:26,209 --> 00:26:27,239 it's redundant. 317 00:26:27,250 --> 00:26:28,500 It's repetitive. 318 00:26:29,599 --> 00:26:37,270 So then do we take away the ADD diagnosis once someone has a diagnosis of autism? 319 00:26:37,640 --> 00:26:39,449 And it's not excessive? 320 00:26:39,760 --> 00:26:40,099 Well, 321 00:26:40,109 --> 00:26:40,989 we could, 322 00:26:41,130 --> 00:26:42,829 if we wanted to be precise, 323 00:26:42,839 --> 00:26:47,369 This is really what the manual talks about as making the most sense. 324 00:26:48,699 --> 00:26:49,250 However, 325 00:26:49,260 --> 00:26:50,390 practically speaking, 326 00:26:50,400 --> 00:26:51,790 this gets difficult. 327 00:26:51,800 --> 00:27:02,290 So one reason is that people don't understand the context of this ADD diagnosis and what it means and what it doesn't mean. 328 00:27:03,219 --> 00:27:04,930 And many times after I see a 329 00:27:04,939 --> 00:27:07,349 a client for an autism evaluation, 330 00:27:07,359 --> 00:27:11,079 I'll tell them their diagnosis is autism spectrum disorder. 331 00:27:11,239 --> 00:27:12,719 And then they will ask, 332 00:27:12,729 --> 00:27:15,910 did you also check for ADD I think I have that too. 333 00:27:16,800 --> 00:27:21,949 And so it's a difficult thing to just answer with a couple sentences as you can see. 334 00:27:22,489 --> 00:27:25,150 Do they have executive function difficulty? 335 00:27:25,160 --> 00:27:26,359 Absolutely. 336 00:27:26,719 --> 00:27:36,709 Do they have executive function difficulty that fits into that four subset category that we have as our diagnosis for ADD? Possibly  337 00:27:36,719 --> 00:27:37,790 yes or possibly no. 338 00:27:37,800 --> 00:27:48,400 Depending on the case. And does the executive function difficulty exceed what is generally seen in autism?  Really infrequently. 339 00:27:48,410 --> 00:27:49,260 Honestly, 340 00:27:49,670 --> 00:27:52,079 I have made both diagnoses, 341 00:27:52,089 --> 00:28:00,579 but I don't frequently see the executive function as really standing out higher than you know... 342 00:28:00,589 --> 00:28:02,369 the group of people that I see. 343 00:28:03,780 --> 00:28:04,890 So conceptually, 344 00:28:04,900 --> 00:28:05,640 to me, 345 00:28:05,959 --> 00:28:11,540 it makes no actual sense to talk about autism with and without ADD. 346 00:28:11,979 --> 00:28:12,589 In fact, 347 00:28:12,599 --> 00:28:13,339 at this stage, 348 00:28:13,349 --> 00:28:15,630 in our understanding of the nervous system, 349 00:28:15,949 --> 00:28:27,680 it doesn't make sense to talk about a diagnosis that is ADD that only includes four or so subsets of the executive function skills. 350 00:28:29,040 --> 00:28:36,209 I would propose that it would make more sense to just have a diagnosis that says executive function disorder. 351 00:28:37,050 --> 00:28:45,969 And then you could say comma developmental or comma acquired or perhaps you could list the pattern ... like for this person, 352 00:28:45,979 --> 00:28:48,920 these are the strengths and these are the difficulties. 353 00:28:49,760 --> 00:29:00,569 It would be nice to increase the understanding that saying the diagnosis of autism automatically communicates that there are executive function difficulties present. 354 00:29:02,079 --> 00:29:04,569 That's not really our reality right now though. 355 00:29:05,920 --> 00:29:11,339 So even though that makes the most sense to me as a neuropsychologist, 356 00:29:12,650 --> 00:29:22,829 one of the practical difficulties (aside from people not understanding the terms) is that if we take away the ADD diagnosis for an autistic client, 357 00:29:23,229 --> 00:29:26,390 the individual can't get their attention medication, 358 00:29:26,719 --> 00:29:32,670 even if it has helped their executive function difficulty within the autism spectrum. 359 00:29:33,890 --> 00:29:34,699 Now, 360 00:29:34,709 --> 00:29:41,439 the medication is often not as effective on the spectrum as off the spectrum. 361 00:29:41,619 --> 00:29:44,380 But if someone has been helped by it, 362 00:29:44,500 --> 00:29:47,099 there's no reason to take it away because, 363 00:29:47,390 --> 00:29:47,619 you know, 364 00:29:47,630 --> 00:29:50,670 just because that ADD doesn't entirely fit. 365 00:29:51,239 --> 00:29:54,130 So practically speaking, 366 00:29:54,569 --> 00:30:01,030 they're gonna end up keeping that diagnosis because they understand what it means 367 00:30:01,310 --> 00:30:04,770 snd they don't understand what not having it means. 368 00:30:04,979 --> 00:30:11,170 And also they need medication or benefit from medication that requires that diagnosis. 369 00:30:12,540 --> 00:30:17,469 The other thing that's really a caution that I'd like you to think about... 370 00:30:20,109 --> 00:30:33,630 I really advise a lot of caution when reading things and listening to people speak about ADD and ADHD because we'll start to hear things... 371 00:30:33,640 --> 00:30:34,609 You know, 372 00:30:34,619 --> 00:30:35,489 people will say, 373 00:30:35,500 --> 00:30:35,930 well, 374 00:30:35,939 --> 00:30:38,969 you know what's really common for people with ADD, 375 00:30:39,140 --> 00:30:49,670 it's common that they become hyper focussed or it's common that they have difficulty with social interactions or it's common that they have sensory processing difficulties. 376 00:30:51,680 --> 00:30:52,030 The 377 00:30:52,040 --> 00:31:07,280 the problem with these statements is that the individuals who have received diagnoses of ADD often receive this just because they've had executive function difficulty, 378 00:31:07,900 --> 00:31:11,900 but they haven't had much if any differential assessment. 379 00:31:13,010 --> 00:31:25,439 So we don't know if it's really true that individuals with a pure ADD often have these coexisting features. 380 00:31:26,739 --> 00:31:33,219 Because what makes a lot of sense is that within the ADD population, 381 00:31:33,229 --> 00:31:42,439 there's some subset of it autistic individuals who say I have ADD and I notice that I also have trouble reading social cues. 382 00:31:43,380 --> 00:31:44,109 Well, 383 00:31:44,219 --> 00:31:47,780 the difficulty reading social cues then becomes a 384 00:31:47,790 --> 00:31:51,130 "common feature" associated with ADD. 385 00:31:51,140 --> 00:31:53,239 But we don't know, 386 00:31:53,780 --> 00:31:55,880 does this person have autism? 387 00:31:55,890 --> 00:31:57,150 Have they been assessed? 388 00:31:57,160 --> 00:31:57,520 And, 389 00:31:57,869 --> 00:31:58,770 and if so, 390 00:31:58,780 --> 00:32:08,359 if we get this group of just really pure ADD diagnoses and nothing else explains those features better, 391 00:32:08,650 --> 00:32:12,369 I would love to know what ... kind of... is associated with that. 392 00:32:13,420 --> 00:32:14,670 But at this point, 393 00:32:14,939 --> 00:32:21,119 we really don't know. The research using people diagnosed with ADD... 394 00:32:21,520 --> 00:32:24,770 They don't go through any differential process. 395 00:32:24,780 --> 00:32:25,969 They just look and say, 396 00:32:25,979 --> 00:32:27,739 oh you have a diagnosis, 397 00:32:27,750 --> 00:32:30,670 let's put you in the ADD group and study you. 398 00:32:31,280 --> 00:32:33,890 So you see why this is a huge problem. 399 00:32:34,050 --> 00:32:36,270 It's a very messy group, 400 00:32:36,280 --> 00:32:43,810 a mixed group of people who have executive function problems from childhood. 401 00:32:45,310 --> 00:33:08,609 But it hasn't really been distinguished as to whether other contributors to executive function difficulty may have actually been there rather than just a pure developmental difficulty within these four categories or subtypes/subsets within that executive function definition. 402 00:33:10,469 --> 00:33:15,219 So that was a long meandering explanation, 403 00:33:15,229 --> 00:33:16,660 but really important. 404 00:33:16,670 --> 00:33:19,959 And I'm glad you followed me through those twists and turns. 405 00:33:20,719 --> 00:33:22,780 What do I want you to walk away with? 406 00:33:22,790 --> 00:33:23,760 Let me recap. 407 00:33:23,770 --> 00:33:24,270 Again. 408 00:33:24,750 --> 00:33:28,199 Executive function refers to a series of skills, 409 00:33:28,209 --> 00:33:32,189 not one skill that are linked anatomically, 410 00:33:32,199 --> 00:33:41,599 they hang together in the subcortical frontal systems of the brain and they work together to help us make a cohesive and meaningful product. 411 00:33:42,540 --> 00:33:51,050 ADD was added to the diagnostic manual in 1980 to describe developmental executive function differences. 412 00:33:51,060 --> 00:33:54,630 And that was really a good advancement at the time. 413 00:33:56,219 --> 00:34:01,199 Executive function is not specific to ADD and many, 414 00:34:01,209 --> 00:34:05,250 many things can trigger executive function difficulty. 415 00:34:05,959 --> 00:34:09,209 So we would never want to hear... 416 00:34:09,219 --> 00:34:15,669 executive function difficulty ...and translate that automatically into ADD. 417 00:34:17,688 --> 00:34:25,579 This is where the differential diagnostic process should come in someone presenting with executive function difficulty. 418 00:34:26,089 --> 00:34:27,579 Then we would say, 419 00:34:27,589 --> 00:34:27,878 well, 420 00:34:27,888 --> 00:34:35,039 what conditions that could produce this kind of difficulty may present in the specific student, 421 00:34:35,049 --> 00:34:36,269 client, or patient? 422 00:34:36,519 --> 00:34:40,648 And what would be most likely do they have a medical condition? 423 00:34:40,849 --> 00:34:43,638 Has someone looked for an intellectual disability, 424 00:34:43,648 --> 00:34:45,358 auditory processing problems, 425 00:34:45,368 --> 00:34:46,519 learning disability, 426 00:34:47,399 --> 00:34:47,739 you know, 427 00:34:47,750 --> 00:34:57,810 perhaps an older individual presents with concerns that they have ADD and yet they have some medical issues, 428 00:34:57,820 --> 00:34:58,850 normal aging, 429 00:34:58,860 --> 00:34:59,860 some trauma. 430 00:35:00,270 --> 00:35:02,590 So what has the differential been, 431 00:35:02,820 --> 00:35:04,909 has there been a differential? 432 00:35:06,429 --> 00:35:10,280 What often happens instead is that especially during childhood, 433 00:35:10,290 --> 00:35:12,189 adolescence and young adulthood, 434 00:35:12,340 --> 00:35:26,300 someone presents with executive function difficulty and they're given a diagnosis of ADD without ruling out autism or other possible contributors to the inattention and other features. 435 00:35:27,939 --> 00:35:56,770 This leads to personal stories and articles and research studies about common features in ADD that are actually describing features in this huge mix of individuals with a variety of factors impacting their executive function rather than a research study with a group of people who have features specific to our definition of ADD and do not have other diagnostic conditions like autism. 436 00:35:58,129 --> 00:35:58,739 To me, 437 00:35:58,750 --> 00:36:03,409 it rarely makes sense to describe both ADD and autism. 438 00:36:03,649 --> 00:36:13,639 Usually the ADD diagnosis is describing these four subs skills of executive function when actually there are more like 12 to 15. 439 00:36:14,030 --> 00:36:22,580 And they're describing it in autism where executive function difficulty is always present in some form. 440 00:36:24,379 --> 00:36:40,040 And the diagnostic manual says that ADD should only be diagnosed when it's the diagnosis that explains the features the best you don't diagnose it just because the criteria are met, 441 00:36:40,300 --> 00:36:46,689 you diagnose it if the criteria are met and other things are not better explanations. 442 00:36:47,669 --> 00:36:56,580 I rarely see executive function difficulties in clients that extend beyond what I would expect for the autism profile. 443 00:36:56,800 --> 00:36:59,919 I have seen it certainly and I have diagnosed it. 444 00:37:00,179 --> 00:37:01,739 But by definition, 445 00:37:01,750 --> 00:37:04,139 if it's more than you'd expect, 446 00:37:04,149 --> 00:37:04,459 it's, 447 00:37:04,469 --> 00:37:07,500 it's not going to be common. To me, 448 00:37:07,510 --> 00:37:08,979 it makes sense to talk about 449 00:37:08,989 --> 00:37:18,189 executive function as including a series of sub abilities of which we can look at patterns of strengths and weaknesses in everyone, 450 00:37:18,459 --> 00:37:20,260 including those on the spectrum. 451 00:37:20,879 --> 00:37:22,129 But for now, 452 00:37:22,250 --> 00:37:37,090 we have this tiny subset of executive function characteristics in the DSM five called ADD that I would suggest should be expanded to reflect all of the executive function characteristics with, 453 00:37:37,100 --> 00:37:39,770 with specifiers like developmental. 454 00:37:40,610 --> 00:37:42,959 Thank you for listening to the recap. 455 00:37:42,969 --> 00:37:48,899 Thank you for going on this pathway of information with me today about executive function, 456 00:37:48,909 --> 00:37:50,540 ADD, and autism. 457 00:37:50,800 --> 00:37:51,919 In future episodes, 458 00:37:51,929 --> 00:37:57,370 we will break down some of the subsets of executive function and talk more about those. 459 00:37:58,219 --> 00:38:07,370 My favorite book series on Executive Function is The Smart But Scattered series which I will link in the show notes. 460 00:38:07,979 --> 00:38:09,439 Now there are many, 461 00:38:09,449 --> 00:38:16,669 many good books and resources on executive function and I certainly have not read or reviewed them all. 462 00:38:16,909 --> 00:38:20,729 You are encouraged to use the resources that best meet your needs. 463 00:38:20,979 --> 00:38:23,530 So look for the link for the smart but scattered. 464 00:38:23,540 --> 00:38:26,449 If you don't already have a series that meets your need, 465 00:38:26,889 --> 00:38:34,830 I do want to say that I don't get any financial compensation for recommending any of the resources that I list for you in my podcast episodes. 466 00:38:34,939 --> 00:38:39,370 These are just recommendations from things that have helped me in the past. 467 00:38:39,379 --> 00:38:47,659 I hope you have a great few weeks, and I look forward to you joining me for our next episode on Executive Function.  

Have you ever struggled over whether to accept an invitation or opportunity? Should I say yes, or no? Join Dr. Regan as she discusses the importance of identifying goals and asking "what might that look like" before making a final decision.    Previous podcast episodes mentioned: Attention Deficit Disorder and Autism: Similarities and Differences Dr. Regan's Master Class for Clinicians: Zur Institute: Master Class   Dr. Regan's Resources Book: Understanding Autism in Adults and Aging Adults, 2nd ed Audiobook Book: Understanding Autistic Behaviors Autism in the Adult website homepage Website Resources for Clinicians   Read the transcript: 1 00:00:07,670 --> 00:00:08,520 Hi there. 2 00:00:08,529 --> 00:00:13,520 This is Doctor Regan joining you for an episode of Autism in the Adult podcast. 3 00:00:13,760 --> 00:00:15,029 I'm your host. 4 00:00:15,039 --> 00:00:18,739 I'm also a neuropsychologist, author and speaker, 5 00:00:19,000 --> 00:00:24,719 a certified autism specialist and the parent of a teen on the autism spectrum. 6 00:00:25,850 --> 00:00:29,040 You are joining me today for an episode entitled, 7 00:00:29,049 --> 00:00:30,620 "what might that look like?" 8 00:00:30,909 --> 00:00:35,240 One of the things that clients and families often ask me is, 9 00:00:35,250 --> 00:00:39,909 "should we plan on this" or "should I say yes to this?" 10 00:00:40,189 --> 00:00:40,669 Now, 11 00:00:40,680 --> 00:00:48,659 this could mean being the best man at a family wedding or taking a family vacation to a cabin in the woods. 12 00:00:49,419 --> 00:00:53,509 It could mean accepting a full time job in an office setting. 13 00:00:54,299 --> 00:00:55,029 Now, 14 00:00:55,529 --> 00:00:58,509 my response is rarely yes or no, 15 00:00:58,520 --> 00:01:01,270 but rather "what might that look like?" 16 00:01:02,590 --> 00:01:05,519 So before we jump into the topic for today, 17 00:01:05,529 --> 00:01:09,559 we are coming up to the third anniversary of this podcast, 18 00:01:09,879 --> 00:01:19,639 the first episode launched on August 7th 2020 it highlighted similarities and differences between autism and ADD or ADHD. 19 00:01:20,050 --> 00:01:20,379 Now, 20 00:01:20,389 --> 00:01:33,279 this premiere episode is one of the most popular of the podcast and I plan to expand this topic into a series after today's episode which will further define executive function, 21 00:01:33,550 --> 00:01:41,050 its presentation in autism and ADD, and resources for harnessing the power of executive function. 22 00:01:42,199 --> 00:01:43,089 Secondly, 23 00:01:43,099 --> 00:01:46,930 I want to inform clinicians about an upcoming master class. 24 00:01:46,940 --> 00:01:52,069 I'm offering through Zur Institute about autism across the lifespan. 25 00:01:53,190 --> 00:02:04,459 I received so many emails and messages through my website about people seeking autism informed clinicians to provide them with diagnostic input information, 26 00:02:04,470 --> 00:02:08,919 education and solutions for roadblocks they may have encountered. 27 00:02:09,649 --> 00:02:17,270 So the bottom line is that more clinicians are needed to serve individuals who are searching for this specialization. 28 00:02:17,600 --> 00:02:28,779 And my response has been to offer multiple courses through Zur Institute. It's a continuing education site for clinicians. 29 00:02:29,330 --> 00:02:36,809 My goal is to equip clinicians across various regions to assist individuals in their communities. 30 00:02:36,860 --> 00:02:39,320 When this type of service is needed, 31 00:02:39,979 --> 00:02:51,729 the master class offering will focus on advanced topics and it starts in September space is limited and I'll have the link in the show notes. 32 00:02:52,360 --> 00:02:55,449 So let's jump into our topic for today. 33 00:02:56,380 --> 00:03:10,369 The autistic individual may have opportunities to accept or decline invitations and the invitation may be to enter an advanced academic program rather than the basic program. 34 00:03:10,789 --> 00:03:13,770 Perhaps the invitation is to travel. 35 00:03:14,429 --> 00:03:24,199 The invitation may be to lead a group such as being the best man at a family wedding or presenting research to professionals. 36 00:03:25,720 --> 00:03:33,619 My experience is that there's value in viewing the invitation not so much as a yes or no question. 37 00:03:33,889 --> 00:03:35,369 Do I accept this? 38 00:03:35,380 --> 00:03:36,580 Do I say no. 39 00:03:36,759 --> 00:03:38,880 But by asking ourselves, 40 00:03:38,889 --> 00:03:40,410 what might that look like? 41 00:03:41,149 --> 00:03:41,710 A yes, 42 00:03:41,720 --> 00:03:47,160 no view would be to see the invitation as a formed and complete package. 43 00:03:47,289 --> 00:03:51,080 So if I say yes to being the best man, 44 00:03:51,089 --> 00:03:53,080 I will plan the bachelor party, 45 00:03:53,089 --> 00:03:54,240 make a speech, 46 00:03:54,380 --> 00:03:55,020 toast, 47 00:03:55,029 --> 00:03:56,509 the couple at the reception, 48 00:03:56,520 --> 00:04:00,869 et cetera saying no to the invitation means I'll, 49 00:04:00,880 --> 00:04:03,440 I won't participate in these activities. 50 00:04:03,990 --> 00:04:05,360 But instead of a yes, 51 00:04:05,369 --> 00:04:06,589 no mindset, 52 00:04:07,100 --> 00:04:11,199 we can often talk through alternatives by asking, 53 00:04:11,210 --> 00:04:12,919 what might that look like? 54 00:04:13,300 --> 00:04:14,990 What might it look like to say? 55 00:04:15,000 --> 00:04:15,729 Yes, 56 00:04:16,170 --> 00:04:19,630 in a way that works for me and for the people around me. 57 00:04:22,149 --> 00:04:26,200 The first point to think about is what is the ultimate goal? 58 00:04:26,209 --> 00:04:28,320 What is the desired outcome? 59 00:04:29,779 --> 00:04:36,600 The goal for a vacation with family members may be to have relaxing experiences, 60 00:04:36,660 --> 00:04:43,480 to see natural landscapes that you've never seen and to connect with other family in a meaningful way. 61 00:04:44,829 --> 00:04:50,709 The goal for presenting your research to professionals may be to advance your career, 62 00:04:50,720 --> 00:04:57,040 make professional connections with others and highlight your role in the work that's been done. 63 00:04:58,730 --> 00:05:09,549 Identifying what a good outcome would look like is empowering because it helps us identify a handful of core foundational objectives. 64 00:05:10,029 --> 00:05:12,640 And when we work toward those objectives, 65 00:05:12,649 --> 00:05:17,220 we can release some of the trappings that may be part of the activity, 66 00:05:17,230 --> 00:05:23,959 but they're really not core to what we're going after for the individual, 67 00:05:23,970 --> 00:05:26,440 considering a full-time office job, 68 00:05:26,470 --> 00:05:31,089 he may decide that the foundational goals would be to have work stability. 69 00:05:31,510 --> 00:05:34,140 If he's currently doing consulting work, 70 00:05:34,149 --> 00:05:35,200 for example, 71 00:05:35,290 --> 00:05:35,769 he would, 72 00:05:35,779 --> 00:05:45,109 he may want more of a predictable salary and to have his name associated with a company that has a respected reputation in his field. 73 00:05:46,239 --> 00:05:53,489 So the first step you can focus on is determining what would be a good outcome. 74 00:05:54,480 --> 00:06:02,549 What would it look like in this situation to really dive in and also to feel like things went well. 75 00:06:04,519 --> 00:06:10,970 The first step you should focus on is determining what a good outcome would look like in this situation. 76 00:06:11,589 --> 00:06:15,779 What would a good outcome for participating in the wedding look like? 77 00:06:16,140 --> 00:06:21,519 What about going on a family vacation or accepting an office job? 78 00:06:22,910 --> 00:06:32,970 The second part after we've identified what the core features we're going after are those core foundational goals? 79 00:06:33,179 --> 00:06:35,000 We can ask ourselves, 80 00:06:35,010 --> 00:06:36,459 what might it look like? 81 00:06:36,470 --> 00:06:41,559 What might the situation look like that would allow for those outcomes? 82 00:06:42,480 --> 00:06:44,950 So let's go back to the examples. 83 00:06:45,410 --> 00:06:49,690 The gentleman invited to be best man at an out of town family wedding. 84 00:06:49,700 --> 00:06:51,200 Let's call him Joe. 85 00:06:51,790 --> 00:06:54,510 He may realize his instinct is to say, 86 00:06:54,519 --> 00:06:55,160 no, 87 00:06:55,679 --> 00:06:58,809 he knows that he gets overwhelmed in crowds. 88 00:06:58,820 --> 00:07:09,809 He dislikes being the center of attention and he relies on routine and specific favorite activities to remain grounded in daily life. 89 00:07:10,170 --> 00:07:24,489 He feels pulled in different directions because he wants to support his family member and he knows that it's really an honor to be asked to connect with the couple in this way at the ceremony. 90 00:07:25,890 --> 00:07:28,390 So Joe and his family may want to discuss, 91 00:07:28,399 --> 00:07:31,570 what would it look like for you to be best man? 92 00:07:31,809 --> 00:07:36,630 What might it look like for Joe to be best man in a relational, 93 00:07:36,640 --> 00:07:38,899 satisfying and meaningful way? 94 00:07:38,940 --> 00:07:44,929 But in a way that also offers him the freedom and the space to take care of his needs. 95 00:07:45,790 --> 00:07:46,920 So at this point, 96 00:07:46,929 --> 00:07:57,320 there is a commitment to the core goals and there is flexibility with the trappings that might otherwise go along with a wedding ceremony. 97 00:07:59,109 --> 00:08:00,369 In the case of the wedding, 98 00:08:00,380 --> 00:08:02,769 Joe may have a separate hotel room, 99 00:08:02,779 --> 00:08:07,369 so he has a quiet alone space to regroup as needed. 100 00:08:08,350 --> 00:08:20,239 Joe may know that he is grounded and centered when he gets pressure inputs in his muscles and joints and he gets these inputs at home with a weighted blanket, 101 00:08:20,260 --> 00:08:22,339 rock climbing and bike riding. 102 00:08:23,239 --> 00:08:36,650 He's decided to choose a hotel that has a swimming pool and an elliptical machine so that he can get these pressure inputs in ways that will still feel grounding to him. 103 00:08:38,489 --> 00:08:48,789 Joe also plans to use small noise canceling earbuds as needed just to shield himself from some of the noise in crowded areas. 104 00:08:48,968 --> 00:08:50,289 They're barely visible, 105 00:08:50,299 --> 00:08:55,698 they help him a lot and it'll be a step toward really increasing his comfort. 106 00:08:56,940 --> 00:09:00,880 Joe and his family agree that he won't attend the bachelor party, 107 00:09:01,150 --> 00:09:09,630 but still he'll have a time that evening where he and the groom have a private drink together to celebrate the union. 108 00:09:11,020 --> 00:09:18,960 Joe also decides to record a video of him toasting the couple rather than making a live toast. 109 00:09:19,409 --> 00:09:26,979 These things in combination with others really help him or regulate himself to have a relation, 110 00:09:27,010 --> 00:09:33,950 meaningful contribution at the ceremony and to also protect what his nervous system needs. 111 00:09:34,820 --> 00:09:38,260 The main points are that Joe and his family are thinking, 112 00:09:38,450 --> 00:09:39,950 what might this look like? 113 00:09:39,960 --> 00:09:47,789 What do we want to work toward and how can we best get there with a mindset toward getting everyone's needs met. 114 00:09:49,020 --> 00:09:50,140 Similarly, 115 00:09:50,150 --> 00:09:53,250 the researcher invited to present her work. 116 00:09:53,260 --> 00:09:54,030 Let's call her, 117 00:09:54,039 --> 00:10:03,669 Susan may avoid the invitation because handling unexpected situations during a presentation is very stressful to her. 118 00:10:04,080 --> 00:10:10,799 She also really shies away from being the center of attention and speaking in front of others. 119 00:10:11,409 --> 00:10:19,219 If she does present her goals would be to take credit for her work and to connect with like minded professionals. 120 00:10:20,369 --> 00:10:26,169 Perhaps her focus on what might this look like leads to the following plan, 121 00:10:27,190 --> 00:10:35,840 Susan and her mentor decide to present the information together with specific slides identified for each of them. 122 00:10:36,559 --> 00:11:02,320 So this plan allows Susan to have an experienced partner to guide her through unexpected glitches and it also ensures that Susan can count on presenting specific material but also have expected breaks while her mentor is speaking during the question and answer section at the end of the presentation, 123 00:11:02,539 --> 00:11:13,679 Susan will take the lead on questions she feels comfortable with and her mentor may cue and structure her thoughts by adding prompts like saying Susan, 124 00:11:13,690 --> 00:11:19,400 this may be a good time to discuss your findings in the area of XY or Z. 125 00:11:21,340 --> 00:11:37,650 So what might that look like process allowed Susan to work toward her desired goals without taking an all or nothing approach to all of the trappings that may typically accompany a professional presentation. 126 00:11:38,219 --> 00:11:47,140 So the first thing we talked about was figuring out what's foundational in the goals and then figuring out how to get there, 127 00:11:47,150 --> 00:11:52,770 what might it look like to accommodate these goals and to let some other things go. 128 00:11:54,070 --> 00:11:57,070 The third thing to think about is when to say no. 129 00:11:57,840 --> 00:11:59,729 So having said all this, 130 00:11:59,739 --> 00:12:12,960 there will be times when what might this look like when that process leads to the conclusion that really this is probably unlikely to help achieve our best, 131 00:12:12,969 --> 00:12:14,179 our best outcome, 132 00:12:14,190 --> 00:12:15,369 our best goals. 133 00:12:16,030 --> 00:12:17,479 Um So saying, 134 00:12:17,489 --> 00:12:20,460 no may be the best decision in that case, 135 00:12:21,900 --> 00:12:27,979 although there would be benefits to finding a compromise that meets the needs of multiple people. 136 00:12:27,989 --> 00:12:45,590 The process may be unrealistic in a particular situation and that may be because the individual's needs at that time are so high in this season of struggle or it may be because features of the situation just can't be adjusted. 137 00:12:47,289 --> 00:12:53,179 Let's take the consultants situation who's considering a full-time office job. 138 00:12:53,390 --> 00:13:15,960 Let's call him a the best answer for him may be no if he is in an unusual season of struggle and maybe he's having difficulty consistently getting his consulting work done and to then switch to a setting that would be more challenging for him may really not be good timing, 139 00:13:16,719 --> 00:13:22,520 his needs as an individual may be so far from what the job can offer him. 140 00:13:22,770 --> 00:13:25,729 That the best answer in this season is no. 141 00:13:27,179 --> 00:13:28,309 Alternatively, 142 00:13:28,320 --> 00:13:32,619 the answer may be no if he's doing well in his consulting work. 143 00:13:32,830 --> 00:13:42,119 But there are core features of the job that would prevent him from having the flexibility that he would really need to thrive. 144 00:13:42,809 --> 00:13:47,280 He may realize that he would need a hybrid work model, 145 00:13:47,289 --> 00:13:50,280 combining office work and remote work. 146 00:13:51,070 --> 00:13:57,289 He may have the self awareness that working on new business proposals keeps his interest level up, 147 00:13:57,650 --> 00:14:06,549 but he needs help maintaining interest in projects that feel like old hat that the work can get boring very quickly. 148 00:14:06,640 --> 00:14:21,630 And the consulting job allows him to pick and choose the types of projects that he does and for things not to get stale if the office job offers him stability in one sense, 149 00:14:21,729 --> 00:14:26,719 but a lack of flexibility to kind of meet in the middle. 150 00:14:27,530 --> 00:14:30,950 He may need to say no to that invitation. 151 00:14:31,330 --> 00:14:33,929 Uh Based on what he knows about himself, 152 00:14:38,130 --> 00:14:42,099 an individual invited to come along for a family vacation. 153 00:14:42,239 --> 00:14:44,090 Let's call her MEREDITH. 154 00:14:44,460 --> 00:14:49,940 She may realize that no is the answer that makes the most sense in her season. 155 00:14:50,799 --> 00:14:53,890 After thinking through what might this look like, 156 00:14:53,900 --> 00:15:02,969 she can't envision any way that realistically meets her needs and achieves the goal of connecting with family on this trip. 157 00:15:04,080 --> 00:15:05,250 For example, 158 00:15:05,260 --> 00:15:14,809 she may have a really severe fear of flying and taking multiple planes is the only way to participate in the vacation as planned. 159 00:15:16,049 --> 00:15:23,179 MEREDITH may realize that her core goal is to connect with two family members in particular. 160 00:15:23,880 --> 00:15:26,580 So her next thought process might be, 161 00:15:27,229 --> 00:15:30,859 I'm going to have to say no to the invitation of the trip. 162 00:15:30,929 --> 00:15:34,429 But how else could I connect with those family members? 163 00:15:34,500 --> 00:15:37,849 Even I'm if I'm going to turn down this invitation, 164 00:15:39,489 --> 00:15:55,979 this process of evaluating invitations and opportunities by asking what might that look like can help us identify what our core goals and needs are while adjusting or releasing things that really aren't foundational. 165 00:15:57,039 --> 00:15:59,809 The decisions often don't need to be all or nothing. 166 00:15:59,820 --> 00:16:03,750 Although after thinking through what might this look like? 167 00:16:03,940 --> 00:16:08,150 We might see that some opportunities just aren't a good fit. 168 00:16:10,030 --> 00:16:22,359 I hope you have invitations that help you grow toward your goals and that your decision making process can also reflect your values and your needs at all seasons of your life. 169 00:16:22,460 --> 00:16:24,500 Thank you for joining me today. 170 00:16:24,750 --> 00:16:36,599 The next episode will launch our new series on Executive Function and clinicians ... check out the link to the master class opportunity with Zur Institute coming up in the fall.  171 00:16:36,690 --> 00:16:41,710 I hope you can join me next time for our episode on Executive Function.