Podcast Transcript
Organization Skills Training for Children with ADHD
Summary:
Teaching organizational skills to children with ADHD, whether they are on medication or not, can be effective for handling their functional problems, including difficulty managing school papers and understanding what they need to do for assignments. Learning organizational skills lasts longer than behavioral approaches and appears to improve brain connections that are needed for attention and behavior control. The skills training needs to be modified according to the age of the child, and teaching smaller groups of children delivers better results. Medication may also help to improve organizational skills for some children.
Different types of professionals who have a good understanding of ADHD and are patient with children with ADHD can deliver organizational skills training, including behavior therapists and educators. Parents must be invested in the training for it to succeed, and children can be motivated to learn the skills with rewards and creative training delivery. The treatment is billable as psychotherapy and is more effective when delivered more than once a week.
Margaret Sibley, PhD
Margaret Sibley is an associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine and a clinical psychologist at Seattle Children’s Hospital. She has authored over 100 scholarly publications on ADHD in adolescence and adulthood, including a comprehensive therapist’s guide to treating ADHD in teens. Dr. Sibley’s research is funded by the National Institute of Mental Health and the Institute of Education Sciences.
Richard Gallagher, PhD
Richard Gallagher is associate professor of child and adolescent psychiatry at the Child Study Center, NYU School of Medicine. He specializes in anxiety disorders, ADHD, and learning disorders. He has been a co-principal investigator on NIMH grants investigating executive function deficits in children with ADHD and how to overcome those deficits. Dr. Gallagher has presented programs at ABCT, the American Psychological Association, and the American Academy of Child and Adolescent Psychiatry. He has been an invited speaker at the International Convention of Child and Adolescent Psychiatry, the Canadian ADD Resource Alliance, the American Professional Society of ADHD and Related Disorders, regional professional organizations and schools. He is coauthor on numerous papers, first author of Organizational Skills Training for Children with ADHD: An Empirically-Supported Treatment and The Organized Child (for parents), and coauthor of the Children’s Organizational Skills Scale. Dr. Gallagher has provided content to the Today Show, Good Morning America, CBS Evening News, The New York Times, and Parents, and has conducted many parent workshops.
Learning Objectives:
- Describe the co-existing functional problems in children with ADHD
- Explain the considerations of effective ADHD medication management.
- Explain the importance of integrating organizational skills training for children with ADHD.
Announcer: You are listening to Pocket MD training on ADHD in children and adults.
Dr. Margaret Sibley: Hi. Welcome to the podcast. I am Maggie Sibley. I'm a psychologist and a researcher at the University of Washington School of Medicine, and today I am here with Dr. Richard Gallagher. We're going to be talking about organization skills training.
Dr. Richard Gallagher: Hi, I'm Richard Gallagher. I'm a psychologist at the New York University Grossman School of Medicine. We've been working with understanding ADHD and organizational problems in younger kids, and I'm happy to be talking about that.
Dr. Margaret Sibley: We're going to be talking about an approach that you've been doing for a while called organization skills training, and it's different from traditional behavioral approaches for ADHD. I wonder if you could talk a little bit about that.
Dr. Richard Gallagher: Most behavioral approaches for kids with ADHD rely very heavily upon providing them with rewards for behaviors that they need to demonstrate. Many people would say that it doesn't really teach the kids skills, and we wanted to be able to see if we could work on teaching skills to be able to handle the functional problems that kids have at school with managing their papers, understanding what they have to do for their assignments. We heard a lot of things from parents and teachers and clinicians that these things were really a major concern, even when kids were doing pretty well on medication, and that their attention was changing, their impulsivity was changing, and their hyperactivity was changing, but they were still having these issues with getting the materials home back and forth and setting up their time planning for getting work done, like book reports, and getting things done on time.
There had been prior work on teaching kids skills, such as the slowdown approach or doing methods for kids to get involved with self-talk, and my collaborator, who asked the person that initiated this, Howard Abikoff, had actually done some tests with that approach and found that it didn't work out so well with kids with ADHD. They did well in the sessions and in the meetings, but it didn't carry over into their real lives. So we wanted to be able to have this balance of some behavior therapy, but then also seeing if we deal with some more practical kinds of skills that are really impairing the kids, could that change things.
Dr. Margaret Sibley: So, this approach really came out of some earlier work where they were separately doing a treatment approach with the kids and training them to self-regulate. And they were also doing an approach with the parents and teaching them behavioral strategies. And then it sounds like your team realized that, hey, maybe we should put these two together and actually get something that's doubly effective, maybe.
Dr. Richard Gallagher: Right. And we also thought about doing it in a way that was, again, very specific to the situations. The prior work with the kids, like with self-regulation, was teaching the kids how to get involved with problem-solving, and how to be able to bring out these skills, about slowing down your approach and generating alternatives. That had worked with kids that didn't quite meet the criteria for ADHD, but when it was tried out with kids with ADHD, again, they did well in the training sessions, but they didn't carry it over. We thought instead, when dealing with schoolwork, if we really work on having the kids learn a skill specifically for writing down their assignments, specifically for making sure their backpacks are neatly organized and that they have their papers, specifically for setting up a schedule to do their homework and thinking about the time it's going to take to do that, that we might have better success.
Dr. Margaret Sibley: So it's really focused, it sounds like, on the daily life struggles and tasks that kids have to complete and it's more maybe hands-on a little bit.
Dr. Richard Gallagher: Right. Yes, it was like at the specific situation of where the kids are actually carrying out the actions and that's where we thought we would possibly get ahead.
Dr. Margaret Sibley: So is there any research on this program that you can share with our listeners?
Dr. Richard Gallagher: Fortunately, we have a good amount of research, and that's why we get involved with trying to say that this is a good thing to do. We were effectively supported by the National Institute of Mental Health, first for a treatment development grant, a really interesting grant where they say, "Give us a general idea and we will develop this in a couple of different steps." And there was a grant proposal for an innovative treatment for kids with ADHD; Dr. Abikoff wrote that, and we worked together on modifying it and we got funded, so we were able to go from the ground up. And then once we found good information from that in a pilot study, we then were able to get funding for a randomized control trial. With 158 kids, a rather large sample, we were able to pinpoint that this program was more effective than a weightless control group and even more effective than a program that was teaching the parents just behavioral modification for these end results. This program ended up having a more long-term effect and more effect in the school situation.
Dr. Margaret Sibley: It sounds like that study basically found that the traditional behavioral parenting curriculums that a lot of people have implemented from years are helpful, but that this approach adds something incrementally to those approaches.
Dr. Richard Gallagher: Right, and it was also something when we had a waitlist control group. We presented parents with a neutral description of the two programs. One, you as parents, you're going to learn a lot, we're going to work with you a great deal to learn about rewarding your kids for having all their materials, rewarding your kids for getting things done on time. You're going to get really good at that and we're going to teach your kids skills and we'll have you work on some supports that are some behavior modification, but we're mostly going to be working with your kids. And 95% of the waitlist parents said, "We want to do the one where the kids get skills." That's why we thought this would be a useful thing to continue to send out and have people learn. And then we also did in the two-year follow-up, we found that the kids in this one where they learn skills did last longer; the kids held onto it.
Dr. Margaret Sibley: So it sounds like this is something parents are looking for, too. It's something that is valid to them and is really potentially going to be more engaging for families if it's a treatment that makes sense to them.
Dr. Richard Gallagher: We hope so, and we think that is the case. We have been doing some other subsequent studies, and looking at variations in the program and working in that regard, and we still get people that are quite interested in this. And the focus on school was also something that was driven by what people said. Parents said, "Yes, my child's closet is a mess, my kids are misplacing their toys, but we're really concerned about how this is affecting school. We're getting lots of reports from teachers and we have oftentimes daily meltdowns around the homework time."
Dr. Margaret Sibley: Yes, I think I can relate to that. In the adolescent treatment that we do, we initially were interested in treating any potential concerns that teens with ADHD were having, but everyone was telling us, "I really just want to focus on school, making sure they don't fail the grade." And so we really shifted, I think, towards the academic applications of managing your ADHD, even though there are other things that people need help with. And there are opportunities to tailor these programs, too, for specific needs outside the academic context when clinicians have the freedom to do that, which is nice, keeping their room clean at home and things like that. So, what do we know about if this treatment can impact kids' brain functioning?
Dr. Richard Gallagher: We are getting involved with doing some studies on that right now. After doing this work, we started collaborating with one of our neuroscientists, a person that has really been at the forefront of understanding the ADHD brain, Dr. Xavier Castellanos. We thought perhaps if we take a look at the resting state activity of the brain, can this program, if it is effective with kids, change some of the resting state connections that are observed—kids with ADHD, and adolescents and adults as well.
There's pretty good findings that suggest that the areas of the brain that help with attention control and behavior control, they're not so well connected in the ways that you find them to be connected with persons that don't have the condition. And we wondered whether or not the program could actually enhance those connections, make the brain activity look more similar to what's typical. We do have some preliminary information. We have presented this in peer reviews for posters, but not in the literature yet. And again, we got another funding to be able to see about testing that, and we're in the midst of doing this randomized control trial right now. Information so far suggests that there is a connection that as the kids improve their organizational skills, then these brain connections do change. And we will be finishing this up this year with a sample of about, we hope, between 75 and 100 kids.
Dr. Margaret Sibley: That is really a fascinating avenue for research because there's so much attention on, Can we discover our way to train the brain to work better cognitively? And a lot of times people are thinking about whether computer games can do that or something that's a practice of direct training, like how we would lift weights or something for physical strength. But what you're saying is, basically, just by practicing these daily habits and doing it in a consistent way, we may actually be training the brain even better that way.
Dr. Richard Gallagher: It's what would be described as almost in some ways a bottom-up effect, that you change the behaviors and maybe then you change some of the behaviors within the brain as opposed to some of the other work which is designed to be a top-down effect, change the brain activity and then you change the outside activity. And the ones that are doing top-down work are remote from what people are doing, the games that kids are playing. They're playing things in worlds that are different than our real world. I think that this is real-world and possibly making an impact later on.
In some ways, I've been thinking about it in a bit of a cynical way, in terms of, well, if you change your behavior, why wouldn't that change brain behavior? Everything that we have known about behavior comes from the brain, so why wouldn't it do that? It's nice to see that it's looking like that is true. And then hopefully it'll help us understand a little bit more about what are the brain areas that are responsible for these kinds of specific day-to-day functional skills and hopefully lead to some other work that advances the whole field.
Dr. Margaret Sibley: Yes, thinking about the reverse of that is interesting. There's already been a lot of science that's trying to understand the ADHD brain and a lot of it's based on MRI studies. But being able to say, "Okay, we've behaviorally observed a change in a child. Therefore, the brain must be doing something to mirror that change," and maybe that in and of itself can teach us more about the ADHD physiology because we can look back and see what is changing for a person with ADHD when they're getting better.
Dr. Richard Gallagher: Right. And we will have some variations, and we hope that we'll have enough information to know not everybody improves with treatments, and that's true for us as well. And that we can see what might be the differences in the brain activity of the kids that do benefit and the ones that don't. And then can maybe even get into more prescriptive work knowing, okay, this works for some people but not others. And so what do we develop for those others?
Dr. Margaret Sibley: And that's the future, I think, for all the different treatments in the ADHD treatment toolbox, is figuring out how we can combine them and figure out what works best for which person. I think it's really great that we're enhancing that toolbox and that this treatment is available for people. So, what age of children do you think this treatment works for?
Dr. Richard Gallagher: Our work has been specifically with data we think works with kids—it's between third, fourth, and fifth grade kids. So, we think that's where it is working. We did do some preliminary things with older kids, but then your program came out and it really looked like there was good solid evidence, so we decided to see about using that program clinically in our practices. I suspect that these efforts can be useful for older kids as well. I think that in our case, in some ways the activities are a little bit challenging for the younger kids, and then older kids with more cognitive capacity can probably use some of the things that have to do with time management and planning probably a bit more independently than the kids that we work with, where we have to be supported with by their parents to really implement those skills well.
Dr. Margaret Sibley: I think that some of the tools for organization skills are the same whether you're a third grader or a 38-year-old, but it's a matter of how you fit them to the life that you have. One important piece of development as people get older is being more independent in your application of those skills, your decision-making about what skill is the best thing to use at what time. I think that there are certain teenagers with ADHD, that's the age group I work with that actually would work really well with your approach more than ours, because they need a higher level of scaffolding and maybe aren't ready for all that independent decision-making yet. So, I do think trained clinicians should be able to read the different options and think about, "Okay, what does this particular kid need?" And I think that's an important piece.
Dr. Richard Gallagher: We're a clinical setting as well as doing research, and I have a number of colleagues that have gone through postdocs working with us who are now in our clinical faculty. Some of them are doing that, especially with kids around sixth grade. So, they're saying, "Let's do things a little bit more like the younger program as opposed to the older program," and they are modifying things in that fashion. It does seem to make sense to pick and choose.
Dr. Margaret Sibley: Yes, there's definitely a transition age in middle school where some kids are capable of more than others. And I agree, a one-size-fits-all approach isn't always the best way to think about it. What if people are in a setting where they are compelled to deliver treatment in a group? How do you handle that?
Dr. Richard Gallagher: We had done some work with groups that were first, we had an opportunity to work with some middle schools, and we did try groups with that. And we did find that was useful in groups of about four. Again, I know that your work has been working with groups and has found some good indications. With younger kids, we also have done pilot work ourselves within the school setting, having people in the school deliver the program, again, for about three or four kids. You get more than that, it gets to be pretty tough. These kids are pretty lively, and you want to keep them focused.
A group of colleagues of ours from the Children's Hospital of Philadelphia actually got a grant to be able to study this in a controlled study. There are indications that this is really having a pretty positive effect on the kids that were in the group. And again, this was delivered by school persons. They were trained, they were supervised, they were monitored, but they weren't necessarily persons with doctoral level degrees. They were educators and counselors that had master's degrees oftentimes, and the kids really liked it.
Dr. Margaret Sibley: Yes, I think you're right about the size of the group being an important factor. So our groups are for, I think right now, we're running 12 to 16-year-olds in the groups. And now we're even doing it over Zoom, telehealth, and that introduces additional challenges. But we usually have two group leaders for maybe 12 kids, so the ratio is six to one, and I think that makes sense. With a little bit older kids, you can maybe squeeze a couple more in, but at the same time, without breaking out into smaller groups for some of the activities, I think a lot of it would be lost on the kids. The smaller the group, probably the better for these treatments.
Dr. Richard Gallagher: Yes, we think so.
Dr. Margaret Sibley: What happens if people are already taking medication? Is that something that you all encourage? Does it make the treatment pointless because the medication's already helping them? How do you think about that?
Dr. Richard Gallagher: Well, it can. Again, and as we were doing this work a while ago, we did a study with regard to looking at medication by itself on organizational skills. It was an interesting study. It was a crossover design; the kids were their own controls. They were either on medication or placebo, and the doctors that were working with the kids were focusing on changing and improving attention, impulsivity, and hyperactivity. They did not know about us keeping track of the organizational skills in the background.
When the children were on medication, they did improve in their organizational skills. They did improve, however, in a way that wasn't as strong as what we found in our first study of the psychosocial treatment, the skills training, and not as many kids got to the average level as the kids in the skills-based work. So, medication does seem to be effective for some kids, and clinically, when people are asking and the kids are brand new and diagnosed and the parents are considering the idea of using medication, we often recommend that they go ahead and do that first. We check with them in about six weeks or so and say, how are things doing?
And some of the kids are doing better in that regard, but some kids are not. Then we go ahead and see about offering this work to them. Our research did include kids on medication and kids off of medication. They still had organizational problems whether they're on medication or not. And both groups of kids got better.
Dr. Margaret Sibley: That is something we found, too, that for the older kids taking medication doesn't seem to impact whether the treatment works or not. It can work for kids on medication and kids not on medication. Medication is helping with a certain set of factors and these treatments are helping with another set of factors. They add up together to bigger improvement overall. But it seems like, I think, that medication doesn't need to be changed necessarily to do this treatment, based on at least what we've seen with the older kids.
Dr. Richard Gallagher: And the other part I think that's important, with regard to even with the longer-lasting medications, a lot of the things that the kids are doing with regard to managing schoolwork and all, it's worn off. There are often kids that are doing things and even the extended-release medications do start to wear down for some kids in the afterschool hours.
Dr. Margaret Sibley: Oh, that's a great point. Yes, so sometimes even just the time of day that you're targeting might help you make a decision about if you're going to use this approach with medication or not. So what are some ways that you make the treatment fun for kids so that they like participating?
Dr. Richard Gallagher: One thing is we do work on making sure that they understand it as something that we don't think that they should feel that they're blamed for having these problems. I'm sure you know with the kids that you work with as well, that they've often been yelled at, they've often been scolded, and maybe it's not really harsh, but it's like, why are you not doing these things? And people don't understand why these relatively simple actions can't be carried out well. So what we have done is we decided to make it something that is not the kid's responsibility completely. We want them to improve it, but it's due to these brain glitches that we say are these little creatures that reside in their brains, and that they give these kids the messages of concern, telling them to do things or to avoid doing things. And we have four of them that have to do with forgetting things, losing things, managing time poorly, and not planning.
And they do things like say, okay, when it's time to write down homework and get ready to know what the details are, oh, the go-ahead-forget-it glitch might say to you, "You don't need to do that. You'll remember it later on." We do a full explanation with the kids and we say, "Well, then maybe when that happens, you get home and you say, oh, I know what I'm supposed to do. I have math work, but I don't know what pages." And they get scolded. The parents get frustrated. Their afterschool program gets frustrated, and the kid starts feeling demoralized. And as that happens, this glitch is over in the corner pointing and laughing and saying, "I got you again." So, we try to make it so the kids want to beat these glitches. We tell them that the executive functions that we think are behind this is their mastermind and we want their mastermind to be more alert and awake and to help them beat these glitches. And we use that throughout the program. We do provide kids rewards for practicing.
We have them do that at home as well, so that they're motivated that way. And we try to make the sessions and the meetings lively. When they do slip up, we point it out and say, "Oh, there's that glitch, it got us and let's work around it." And we also let them recognize that other people are having these glitches hurt them as well. So, we tell them about instances when it got to us as well, and we try to make it so we're in collaboration that way.
Dr. Margaret Sibley: I like how you make it relatable in that way and it makes it seem like this doesn't mean that there's anything wrong with you, but rather this is something that everyone struggles with. And I think that's a really nice touch that this treatment has. So, if there are different kind of providers listening, what kind of provider can deliver this treatment?
Dr. Richard Gallagher: We think that people with a good sense of behavior therapy [who] know how to work with kids can provide it pretty well. And our efforts are in training people in different workshops and programs. That's who we're aiming to have learn this, so it gets spread around to many more people. We have learned through the schoolwork, that if people get some kind of monitoring and assistance and answering questions that they have, I think the good school teachers and persons in the tutoring field might be able to use it as well. In New York City, there's been a group of people that have considered doing it, some occupational therapists, but I do think that there's a variety of people, if they're careful and are patient. One thing we did learn with some of the school personnel was that if they don't really understand and get a real good handle on what ADHD means, that it's not really volitional.
They sometimes would get pretty frustrated when the kids: We taught them the skills, why aren't they doing it consistently? And we had to say, "Well now, it's going to take time. And remember, these kids are having to work around things.” Sometimes we say, and we try to be able to pass along this idea, that adults should recognize that a person with ADHD is a kid fighting their brain. There's some pretty good indications that the kids just have these issues with regard to how their brain just shifts its focus all around, and it happens much more rapidly than other people. And they don't have the mechanisms, again, in their brains to be able to control that shifting in the same way that other people do.
Dr. Margaret Sibley: It's great that so many different professions potentially could have a role in helping with this. I think that makes this treatment really accessible to a range of providers. From your lessons learned, are there any barriers to successfully delivering this treatment for providers? And if so, what can we do about those barriers?
Dr. Richard Gallagher: Getting parental assistance is really important. Parents need to be invested and involved, not extensively, but they do need to put in this review of the skills into their own schedule. So, the family schedule has to change a little bit. We do think that parents that don't follow through on providing the rewards often have the kids get discouraged. And, since COVID, we've been delivering a lot of this virtually, and for some kids staying on the screen and staying involved with the sessions is a bit challenging. So, those are some challenges. With meeting each of those, I think one is to make sure that parents understand what kind of commitment we are expecting of them to do well and to, again, motivate them to say that we have information now that this is effective. That's one part we can add to it.
When parents struggle with it, I think we can get involved in some problem-solving to figure out how they might be able to do better with that. We have found that in addition, with parents, if we do give them this kind of explanation with a little bit more content about how the kids with ADHD are really not doing things on purpose, that they really don't have the structures to be able to help them manage this oscillation of attention, that I think is helpful as well. Then finally, when it is working with the virtual contact, we find that we have to be really creative in showing things to kids on the screen, different little pictures that pop up as rewards for when they're doing well. Sometimes we show these little GIFs of cats dancing and bears clapping and things like that. This bear is clapping for you, and then it keeps them engaged in that way.
Dr. Margaret Sibley: I like that. In terms of resources, can this be billed through insurance if you're in a clinical setting? You mentioned a school setting. So, if you're in a school setting, how do we make sure that resources are available for kids to get this treatment?
Dr. Richard Gallagher: With regard to treatment, this is a treatment. We see it as a treatment and so we bill it as psychotherapy, and that has been effective. Again, the one challenge has been that as tested, this is a twice-a-week program. We did find in the beginning that doing it once a week didn't really connect enough with the kids and get them engaged. So, that's one challenge, getting approval for that. But it's not a challenge for some of the public funding. Medicaid is not a problem for doing it twice a week—it's more private insurance.
But what we hope, with advocacy—in things like different organizations that advocate for persons with ADHD—that once the data is out there, then it might be really a kind of push to say, "Look, this does work, but it needs to be happening a bit more frequently." That has happened with other treatments. It's happened with borderline personality disorder, where it said you need to do groups as well as individual, and it needs to be pretty intense. That's now the approved way of getting treatment for that condition. I hope that this same thing happens with ADHD.
Dr. Margaret Sibley: What those two disorders have in common is that they have these chronic expressions to them. I think that's a really good point that you're making.
Dr. Richard Gallagher: If I may, schools are more of a challenge. We think that this can be done individually in a school setting. We think that the manual that we have is something that people could use in a school setting one-to-one. Again, in a couple of years, unfortunately, with data coming out, the information from the Children's Hospital of Philadelphia program will come out and there will be a protocol that schools can use. But I also think that one of the things I'm concerned about is really advocating for changes and improvements in what kids are getting in schools when they have ADHD. Now, the US Department of Education says that things that are provided for kids with ADHD should be empirically supported. Right now it's a hit or miss in that regard. We hope that more and more information about programs like this can get out there and make schools change their thinking and saying there really are things beyond our common sense that we could implement.
Dr. Margaret Sibley: So, if there are people out there listening and they want to learn how to deliver this treatment, learn more about it or get trained, what would their next steps be?
Dr. Richard Gallagher: Well, in terms of getting officially trained—and we don't have this kind of certification process—we do offer programs and people can contact us for being able to work out that. I've done that with a couple of different centers for treatment of kids, a number of different academic medical centers. We've trained their staff in child and adolescent psychiatry. We've done it with some school districts. We've done it with some larger clinical settings, but that will be one road. We think and we do get royalties from this; there is a book that's been written for therapists that does explain the program and talks about how to do it session to session. I think a person with some good behavior therapy background and some prior work with kids could pick that up and get a pretty good handle on it.
Dr. Margaret Sibley: My last question is, what should a clinician do if the child doesn't want to participate in this? Would you just work with the parent or how would you handle that?
Dr. Richard Gallagher: I think we would want the kids to be interested. We want the kids to be invested, because they do need to sit through the program. They do need to sit through the sessions and practice the skills. If they're being feisty about that and don't want to go along with it, within their original study, we did test a program where parents were learning not to teach the kids the skills, but get really good at get your stuff home. If you get things home and if you turn things in time, we're going to set up a reward program. Show me a record of what you have and if parents are patient with this and give kids a chance to be able to meet these goals with appropriate incentives, many of the kids in that program did do better. They functioned quite well. They didn't hold onto these skills as long, but I think if parents stay with it and if they keep using these incentives, that that's an option. And that would be the way I would go with that.
Dr. Margaret Sibley: Again, that idea that different treatments might work in different situations for different people. And that's a really nice note to end on. Thank you so much for joining the podcast. This has been a great conversation.
Dr. Richard Gallagher: Thank you. It was very good to have it as well. I appreciate it.
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