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Hey everyone. Welcome back to a clinical episode.
Today, my guest is Dr. Jessica Robb Mazzant. She is a Clinical Psychologist whose area of expertise is in the assessment and treatment of ADHD. She’s a remote Associate Teaching Professor for Florida International University and the Assistant [00:01:00] Director for the Professional Counseling Psychology program at FIU. She lives in Colorado and also works for Oliver Behavioral Consultants in Thornton, Colorado.
I met Jessica last fall. She was a presenter in a 6-part class that I took on intervention and assessment of intellectual disability and comorbid concerns. And she presented on the intersection of ADHD and ID, and that’s what she’s here to talk to us about today.
So we get into just some of the background, prevalence of ID, ADHD, and the overlap between the two. We talk about the concept of diagnostic overshadowing and how sometimes we as clinicians have the tendency to attribute all symptoms to something like ID, even though that may not be accurate.[00:02:00] And of course, we dig into the assessment process and talk about how Jessica teases apart symptoms of intellectual disability and ADHD. So as usual, there are a lot of concrete tips to take away from this and lots of knowledge besides.
We are at that time; the next cohort of mastermind groups is starting in the last week of February, the first week of March. Every level is back on the table, so beginner, intermediate, and advanced. So wherever you’re at in your practice, if you’re interested in some group coaching and accountability, this is something to consider. You can get more info and schedule a pre-group call at thetestingpsychologist.com/consulting.
All right, let’s get to my conversation with Jessica Robb Mazzant.
Hey, Jessica, welcome to the podcast.
Dr. Jessica: Thank you, Jeremy. I’m glad to be here. I appreciate you having me.
Dr. Sharp: Of course. Yeah. I’ve been excited to chat with you. Folks probably don’t know this, and I don’t know how they would, but I took a course back in the fall through one of our local Medicaid providers. The course was all about intellectual developmental disability and its different comorbidities and so forth. You were one of the presenters during that course. And this topic really leapt out this IDD versus ADHD question. So I think this is really important. I’m grateful to have you here for a little while.
Dr. Jessica: Well, I’m happy to be here and to talk about this. And that was a [00:04:00] really cool course that you were a part of. You were part of our very first cohort. We’ve done a second cohort since then and gearing up to do a third cohort in the spring. So, I’m really glad to learn that it was useful and informative for you because it’s been a really fun process for us to develop this course.
Dr. Sharp: Yeah, 100%. It was a great resource. I’ll just give a shout-out to anybody who might be in Colorado and want to look the course up or take the course. It was super informative. So appreciate it.
Dr. Jessica: Yeah. And if it’s okay, I’ll talk for just a moment about it.
Dr. Sharp: Yeah.
Dr. Jessica: In Colorado, Medicaid is covered or operated regionally. So there are a number of RAEs or Regional Accountability Entities. And these cover connect some geographical domains around the state of Colorado.
One of [00:05:00] those RAEs realized that they weren’t adequately serving their ID clientele. And part of the reason for that is that many of the providers felt that they were not equipped or didn’t have the necessary competencies to address co-occurring mental health problems and intellectual disabilities with many of those providers saying, we’re familiar with anxiety or we’re familiar with ADHD, we’re familiar with depression, but how do you work with somebody who has specific cognitive or adaptive challenges and still address those concerns?
And so that kind of need was really the genesis of why this course was developed. So the organization that I work with under the direction of the RAE developed this sequence of classes- the first one being how to identify and assess [00:06:00] intellectual disabilities. And then the remaining classes all focused on the topical areas, so intellectual disabilities and anxiety, intellectual disabilities, and trauma. And then the class that I specifically taught was on intellectual disabilities and attention deficit/hyperactivity disorder. And that’s what I’m really excited to talk to your listeners about.
Dr. Sharp: Yeah. You can say, gosh, any number of things about Medicaid and its challenges. This was really a moment where I feel like that regional entity stepped up and provided a really nice opportunity for us. It was really cool.
Dr. Jessica: Yeah, I agree. And they’ve been so lovely to work with on our end too.
Dr. Sharp: Oh, good. It’s always good to hear.
Well, I always start these interviews with this question of why this is important to you? Out of all the things that you could do in our field, why the time and energy into this topic in [00:07:00] particular?
Dr. Jessica: Well, I started out in my graduate career and still to date, really interested in attention-deficit/hyperactivity disorder, ADHD. And not only in the assessment of ADHD, but really how do you treat this chronic condition that has ripples in so many different areas of life for people with ADHD. And that really has largely been the bedrock foundation of my training and my philosophical orientation as well as the work that I do and the training that I provide to students and other professionals now.
Where the ID piece came into it is a little bit more of a circular story. Many years ago, professionally, I moved into a Masters of Mental Health Counseling program [00:08:00] at Florida International University. It’s called the Professional Counseling Psychology Program. And one area of difference that I’ve noticed in training of counselors versus training of psychologists is that with counseling, there is far more emphasis on training a generalist. Somebody who can cover and really provide services for a wide range of existing problems, conditions, diagnoses, situations, et cetera. Whereas in psychology, not everybody, but I think largely we have a tendency to be a bit more specialized or focused in an area.
In addition to that, I also help to run a summer program here in Denver, Colorado. So even though I work for Florida International University, which is in Miami, Florida, I actually reside in the Denver, Colorado area. And one of the amazing opportunities that I’ve [00:09:00] had the privilege to be a part in my professional career is this program called the Summer Treatment Program, which is an intensive behavior modification and social skills training program for kids and adolescents with attention-deficit/hyperactivity disorder.
So there was a summer treatment program out here in Denver and I work in a part-time fashion with an organization called Oliver Behavioral Consultants, which is in Thornton, Colorado. And several years ago, they wanted to take some aspects of the summer treatment program and fold it into their summer programming, but the clientele that they work with are overwhelmingly, I would say, in their behavior analysis department, probably 90% of the clientele have a diagnosis of an intellectual disability, a global developmental delay, or autism spectrum disorders.
The summer treatment program is developed [00:10:00] for treating ADHD, but so many aspects of that program can be transferred to other kids, to other adolescents that are dealing with similar, yet meaningfully different issues. And so this was just a really cool opportunity for me to think about how to meaningfully provide treatment in an intensive format, many similar areas of focus, but to a different group of folks. And I feel like I really, in a baptism by fire nature, got to learn a lot more about developmental disabilities, intellectual disabilities and some of the meaningful differences, but also some of the areas of overlap with other mental health disorders.
And so that really is what uniquely positioned me to help create this training that then you were part of on the co-occurrence of [00:11:00] intellectual disabilities and ADHD. I should have warned you, I’m a bit of a talker. That was probably a longer story than you were expecting to get.
Dr. Sharp: Oh, we’re all good. That’s why I asked that question because the journey to caring about what we care about can be lengthy sometimes but I think that’s important though. It is an interesting journey to prepare these two, right? And just to hear how that happened is meaningful for a lot of folks. You describe an experience that is similar to a lot of us where we have an area of focus that we put a lot of energy into and then get thrust into different situations where we do have to learn, for better or worse, how to incorporate other either diagnoses or populations or whatever it may be. And then all of a sudden you’ve got like a new little niche specialty [00:12:00] when you combine the two, right?
Dr. Jessica: Yeah.
Dr. Sharp: Let’s transition a little bit into the material here. There’s a lot that we could talk about. I know we could talk about that summer program for an entire podcast or two but I’m going to hold back from that and maybe table it for now.
Dr. Jessica: If you ever want to talk about that summer program for an entire podcast, you let me know. That’s one of my favorite topics.
Dr. Sharp: Okay. Be careful what you give permission for. It is interesting. I remember I asked about that during the class when one of the other presenters just mentioned it offhand, and I like jumped in and asked some questions in the chat, and he was like, “Let’s hold off on that and talk to Jessica later. I’m super interested in that but we will table it for now and dig into some of this background around IDD [00:13:00] and ADHD.
I would love to start and just talk a little bit about the overlap of the two, and then later I think we’ll transition into the actual assessment component. But could you maybe just start and share some information about prevalence, comorbidity, that sort of thing and what we’re even looking at with the overlap here?
Dr. Jessica: Yeah, I’ll absolutely jump into that but one of the things that I want to mention is that perhaps compared to other podcasts that you’ve had with other areas of focus on the co-occurrence or the comorbidity between two or more disorders, one of the interesting things about ID and ADHD is that it’s really not been until our current iteration of the DSM-5 that we as a field even recognized the comorbidity [00:14:00] between the two.
Many times, having an intellectual disability would be a rule out for ADHD. And so the information that we have is relatively young, relatively recent and tentative. To be fair, a lot of our really amazing clinicians who work with clients who have both intellectual disability and ADHD or even just features of impulsivity would argue with us and say, this isn’t new and it shouldn’t have been a rule out. But in terms of research, it largely has been.
So I want to put that qualifier out there that I expect in years to come, many of the points of information that I’m talking about now, hopefully will be updated and better [00:15:00] representative of the current state of affairs. I want to put that caveat out there.
Dr. Sharp: That’s great. Sure. Yeah, that’s important. I’m glad you highlighted that. I temporarily forgot that this is a relatively new discussion topic that we could even have just based on the way we’ve done diagnosis in the past.
Dr. Jessica: Yeah. You were asking me though, about the co-occurrence of ID and ADHD. So moving forward, just for sake of my voice, I’ll refer to attention-deficit/hyperactivity disorders, ADHD and intellectual disabilities as ID. But both are considered to be neurodevelopmental disorders. One thing that’s interesting is that for those that have an intellectual disability, the most common comorbidity or the most common other co-occurring [00:16:00] disorder, or I should say mental health disorder, that they could experience as is likely to be ADHD.
That prevalence range of co-occurrences is pretty wide with estimates being between 8 to 40% of folks with ID having co-occurring ADHD. But what that tells us is that this absolutely should be an area that we are assessing or at least screening for when we suspect that there is an intellectual disability. But interestingly, that reverse isn’t also true. So in folks that have a diagnosis of ADHD, having comorbid ID is not the most frequent or the most common comorbidity. It’s probably not even in the top 10. It actually is far lower. So with folks that have ADHD, the most commonly co-occurring comorbidity is oppositional defiant disorder or conduct [00:17:00] disorder, but in folks with ID that have a co-occurring mental health disorder, it is most likely to be ADHD.
Dr. Sharp: Yeah. Just to be super clear, are we talking about kids or adults or both?
Dr. Jessica: A little bit of both. And that’s part of the reason why that prevalence range is likely so wide because we are cutting it across a pretty wide developmental span of studies.
Dr. Sharp: That’s fair. I was actually a little surprised to find that the first piece of information that you mentioned that ADHD is the most common comorbidity in individuals diagnosed with ID. I’m not sure what I thought would’ve been instead, but a little surprising.
I think a big question that I hope we can dig into is truly separating these two [00:18:00] diagnoses, right? Is that possible? And if so, how do we do it? Because I think historically and even in supervising our postdocs and interns and so forth, there’s always this question of like, okay, this person has ID, what else can we really diagnose? How do we know if something is truly separate from that? It comes up with ADHD, with learning disorders, with trauma and sometimes with any number of other things. So, I would love to dig into that question and the nuances of separating these two.
Dr. Jessica: Sure. Well, let’s start first with ADHD. So, as many of us know, the core features of ADHD are inattention, impulsivity, and hyperactivity. And those symptoms of [00:19:00] hyperactivity, those symptoms of inattention, particularly those symptoms of impulsivity also need to cause impairment in daily life activities.
So the person, it’s not just that these symptoms are present, but they’re experiencing, and you can say this a number of different ways, but a deficit in their adaptive functioning. They are underperforming or they’re experiencing impairment in their ability to interact with life on a daily basis. And that impairment could be in school, could be occupationally, can be in their relationships, so their social relationships like their friends or their romantic partners, or it could be relationships with their family members, their parents, their siblings, and their other caregivers.
So it’s not just solely that the symptoms are present, but that they’re causing problems for the person in their life. And if I had to [00:20:00] boil down, ADHD, it’s really those two features. And both of those features, particularly the symptoms, but really both of them were things that were noticed in childhood. So it’s not uncommon for people later in their life, so in their adolescents or into their adult years to say, hey, could this be something that I have been struggling with? Because when I look back retrospectively on my life, I see that these areas of impairment were always there, or these symptoms, maybe they bounced around a little bit or shifted based on the environment that the kid was in, but they were there. It’s something that the person has been dealing with in a lifelong way but they were things that were present in this early phase of development.
Separate from that, in intellectual disability, and particularly how we define it currently is that there is a deficit in [00:21:00] cognitive functioning. Let me pause there for a second because if you would rewind time particularly back to DSM-IV and even before that, the overwhelming emphasis on or what we would say was the essential diagnostic element of an intellectual disability was having a below-expected IQ score.
In the current DSM, so DSM-5, and now recently in DSM-5 text revision, the emphasis or the essential features that we need to look for in the diagnosis are yes, this’s cognitive impairment. So having below expected IQ. Most of the time what we define that as is two standard deviations below the population mean. So for an IQ test that has the mean of 100 and a [00:22:00] standard deviation of 15, we’re usually talking around an IQ of 70 or below, plus or minus a few points on either side, and this and is what’s really important and distinctive in our current classification and problems with adaptive functioning or said another way impairment in daily life activities.
So your question is how do we distinguish between the two? Well, you can probably already infer from the words that I’ve been using is there are some common elements that are required for both diagnoses and really that has to do with this adaptive functioning piece. But the intellectual disability component is really difficulty in, or their difficulties stem from that difficulty with some cognitive [00:23:00] processes and particularly some higher level cognitive processes. So things like abstract thinking, using symbols, problem solving etc.
So those oftentimes are the core areas of impairment that we see whereas with ADHD, really the defining features tend to be more mitotic activity than you would expect based on the age of the person. Acting without thinking about consequence or acting without forethought. So that impulsivity, so acting, speaking, sometimes even, even thinking, leaping to conclusions. And then also that difficulty with attending to ongoing stimuli.
So you could have a person with an intellectual disability who struggles academically, but they’re struggling because they’re not understanding the concept or they’re not understanding [00:24:00] how to apply the concept, or the concept is too abstract as it’s currently being presented for them to make sense of what their existing learning history whereas with ADHD, oftentimes you absolutely can have as you could with any human individual, not understand a concept, not be able to make an inference. But typically with ADHD, it’s not so much of a difficulty or an inability to do that, but more maybe I wasn’t attending to what the teacher said, and so I missed some of those core components of the lesson or core concepts that I was supposed to take in. So now when I’m asked to apply those or to make inferences, I missed them in the first place. And that’s really hard to make an inference or to apply when you don’t have the essential elements of what was being taught to you.
Another example. Let’s say you’re a caregiver and you tell a kid with ADHD to go do something.[00:25:00] If they get distracted along the way, they might not complete the task. But again, it’s not because there’s an inability to do it or a lack of conceptual understanding of what you told them to do, but maybe they didn’t attend when you were telling them the directions. Maybe they got distracted along the way. Maybe other ideas bubbled up to the surface and they impulsively went forth with those ideas instead of following through with the directions that were given. And that’s qualitatively different than somebody who is unable to process the directions that were given because they were beyond their current capabilities. Does that distinction make sense?
Dr. Sharp: It does. I’m going to put you on the spot and see if we can distill this a little bit more, even to say if you are hard-pressed to really pin down the [00:26:00] distinguishing features of ADHD beyond IDD, so looking past any overlap that might happen, what jumps out for you? What symptoms?
Dr. Jessica: Well, I want to make sure as I’m talking about this that we’re not unintentionally conflating the two. So folks with ADHD can often have average to even above-average IQ or cognitive abilities. So having an intellectual disability, one essential piece of that is having a well below average cognitive functioning level. That’s not necessarily true of folks with ADHD. There are many folks with ADHD who have higher average or above IQ levels or cognitive functioning levels.
So I don’t want to send a message that, because we’re talking about the co-occurrence of the two, that [00:27:00] they are the same thing. So really with ADHD, you see the combo or the distinct three entities. So impulsivity/hyperactivity, those two tend to meaningfully hang together in presentation and then also inattention. And sometimes you see features of both that happen at the same time. Call that the combined subtype of ADHD. But really those are the core distinguishing features of ADHD which is again, meaningfully different than the distinguishing features or the core features of an intellectual disability, which is cognitive impairment, and impairment and adaptive skills or adaptive functioning.
Dr. Sharp: Sure. So for me, I think about, let’s just take in attention, for example. Someone with ID might look [00:28:00] inattentive, right? Like trouble getting started on tasks. A little bit spacey, slow work style. A lot of those could be mistaken for the inattentive symptoms of ADHD. I guess my question is, for those characteristics that overlap in that way, are there ways for us to separate the two or is it just a matter of digging in and asking good questions? I’m leaping to the assessment part but…
Dr. Jessica: Sure. Honestly, I think it’s a little bit of both. I can’t tell you, here’s this one psychometric measure that’s going to really distinguish between the two, or here’s the non-psychological test that will help us. But really it is when you have good [00:29:00] interviewing skills and assessment skills and you start to think about when are symptoms occurring? When is impairment evident? With whom is impairment evident? In what context is impairment evident? It starts to help you to answer that question.
And so, one of the things that I think about is that, when you’re working with a kid, for example, with an intellectual disability, you can still have, particularly if they’re verbal, a meaningful, ongoing discussion with them. You can do meaningful ongoing group work with that kid as long as you’re making sure that the information, the demands that you’re putting on them align with their abilities. I think when the demands that are being put on the person are beyond their current capabilities, absolutely you’re going to see some seeming inattentive [00:30:00] behavior because they may not know what you’re asking of them. They don’t know how to produce what you’re asking them to produce or to use the material you’re asking them to use.
And so you want to make sure that you’re scaling your questions, your demands, your interactions appropriately to that person’s presentation in front of you. And when you do that, you don’t necessarily see in attention, for example. Oftentimes you see it when the demands, the ask, the conversation that, whatever is taking place exceeds their current capabilities.
And so one of the things that I would try to assess if I were doing a diagnostic interview is what kind of demands are being put on the person? What kinds of things are being asked of them? Are they able to sustain [00:31:00] attention when they’re doing something meaningful to them? Do we see them in a chronic way or in multiple settings with multiple people having a lot of difficulty focusing or attending to ongoing stimuli, whatever that stimuli is. And if the answer is yes, then that would lead me to think maybe this is ID and ADHD.
Or let’s talk through another example. If you have a person with an intellectual disability and yet they’re still having really high levels of mitotic activity, they can’t sit still. They’re up and down out of their chair, they’re all over there. They’re flipping off the back of the couch. I’m using more extreme examples but that is not characteristic of an intellectual disability in and of itself. And so that might be a time where I say, gosh, the [00:32:00] hyperactivity or the impulsivity seems to be beyond what we would expect with just a person with an intellectual disability. So it becomes an and question for me rather than an or question.
Dr. Sharp: Sure.
Dr. Jessica: And one of the things that I think has happened, and I know I’m personally guilty of this, is historically there has been two things happening simultaneously that I think have muddied the water a bit. But in a lot of the treatment studies we’ve done, assessment studies we’ve done, prevalent studies we’ve done, if someone met criteria for an intellectual disability, they were automatically ruled out of those studies. And so, our understanding of the co-occurrence intellectual disabilities and ADHD was really unclear.
But then in addition, I think one [00:33:00] bias that as diagnosticians we can fall into is this concept of diagnostic overshadowing. Diagnostic overshadowing is when you falsely or in a faulty way attribute everything that you’re seeing or all the clinical presentation that you’re seeing to one explanation as opposed to allowing for the co-occurrence of multiple things happening at the same time.
So if we saw somebody with an intellectual disability who was also being hyperactive or impulsive in their actions or having difficulty with sustained attention, so they’re being largely inattentive, oftentimes there was a tendency to say, well, that’s just the intellectual disability instead of stopping to consider, is that the intellectual disability and something else like ADHD.[00:34:00] Dr. Sharp: Yeah. I’m really glad that you’re bringing this up. I will totally get on board with this idea of diagnostic overshadowing. I think we do that with a lot of diagnoses.
Dr. Jessica: Sure.
Dr. Sharp: And it’s an interesting philosophical question that becomes practical really quickly, which is, how do you balance that with parsimony in our diagnostic process? Like I personally hate a list of diagnoses and it’s ADHD and anxiety and depression and a learning disorder. Sometimes that’s needed and accurate, of course. And The flip side is also really challenging. I have certainly been guilty of this, where we just assume that the ID accounts for any challenges [00:35:00] that the individual might be having.
I don’t know. Its just important. I like that we’re highlighting this and just to drive it totally home and put a really fine point on it, that there are plenty of folks with ID who are not necessarily having trouble paying attention or hyperactive or impulsive in the same way that “pure” ADHD might be.
Dr. Jessica: Sure. And I think the way you just simplified it is really important and helpful to consider. There’s nothing about an intellectual disability that requires, or part of the diagnosis, it doesn’t include difficulty attending. Now, that can happen again when somebody perhaps is a more concrete thinker and the current conversation is more abstract and there’s a mismatch but by default, a person with an intellectual disability is not hugely inattentive or hugely impulsive or hugely [00:36:00] hyperactive.
Dr. Sharp: Right. I think one of the places that I personally get stuck and maybe a lot of other folks do too is when you bring in adaptive functioning. We measure adaptive functioning with so many criteria. There’s so many different areas and symptoms and behaviors that we’re looking at. It is easy to look at some of those and conflate, like you said, with inattention or hyperactivity. And it’s a challenging process but I like that we’re just trying to define it a little bit more here.
Dr. Jessica: You’ll have to stop me if I’ve told you this story before, but I think this was the second cohort of the training that I told this story to. I have one particular, I have many cases out to me, but one particular case from when I was a graduate student, that to me just is diagnostic overshadowing, and one I [00:37:00] fell into that kind of bias. I had a kid I was working with. He was quite young at the time just in kindergarten and really high levels of hyperactivity. He was having huge problems in the school setting, huge problems in the home setting. He was very impulsive. You could picture a tornado swirling and it felt like this kid, even though he was also very funny and very sweet and had all these other wonderful qualities; he was having a rough go of it.
Around February of the year, his mom had come in for a session with me, and she said, “He started doing these dinosaur dinosaur voices.” And I was like, “Tell me [00:38:00] what you mean.” And she would do this voice scuttle noise and model that this is what he was doing. And I started asking about when it would happen and then how would she react when it happened. And I instantly, my mind went to, this is a behavior he’s probably doing because it evokes a reaction from mom. This is a really effective way of getting attention.
And I was really viewing this from in terms of treatment, like a behavioral parent training lens. And so, right away went to this assumption and that if we could help mom to come up with a different way of reacting to these dinosaur noises, then they would definitely decrease over time. And at the time we were using a tool called the Daily Report Card which is a list of individualized goals for the kid. And depending upon how many goals they met during a period of time, they [00:39:00] could have access to preferred activities or rewards in the home setting.
And so I very quickly added dinosaur noises to the Daily Report Card and to find the mom what it is and what it wasn’t. And over time, we’d had many sessions together. She’d bring in her Daily Report Card data and we’d look at the kiddo’s behaviors over time, and it was improving in a lot of areas. But man, this dinosaur noise just kept persisting. And I just kept looking at it as, of course not an ADHD symptom, but under the umbrella of behaviors typical of a kid with ADHD.
Eventually she was like, this is driving me just up the wall and it was time for her to do a medical appointment visit anyway. So she was fortunately meeting with a [00:40:00] developmental pediatrician who is amazing. And I said, well, bring this up to him. Make sure you mention to him the dinosaur noises. And wouldn’t you know, mom came back and actually the pediatrician called me and said, “I think we’re looking at a vocal technique here. I think we’re starting to see the emergence of Tourette’s because it’s not just this vocal technique, there’s some other stuff going on”.
And probably the reason this stands out to me so much is I was just like, as soon as I heard it, I was like, huh. Yeah. Oh my gosh, but I couldn’t conceive of this because of diagnostic overshadowing. I was in the mindset of this is a behavior typical of kids with ADHD that I just wasn’t allowing myself to think more flexibly. I wasn’t allowing myself to think with the, and, I was [00:41:00] attributing everything to ADHD. This was just a manifestation of an impulsive behavior instead of allowing for it to be something qualitatively different.
And I use this separate example because I think it does highlight diagnostic overshadowing, which also can happen when we see the co-occurrence of ID and ADHD. There’s a real tendency to want to attribute aspects of impulsivity or inattention or hyperactivity just to the intellectual disability. This is just because this person is struggling cognitively. Instead of allowing for the and which is, this is ID and there are also meaningful and impactful symptoms of impulsivity and we should also be diagnosing ADHD along with ID.
Dr. Sharp: Absolutely. I love that example. It reminds me of an episode from, I don’t know, maybe a year ago, [00:42:00] maybe six months. I don’t know. Time is strange. But I did an episode with Dr. Stephanie Nelson on bias in our decision-making and how we can really get locked into just seeing what we want to see. That’s funny. It makes me think of a story from that book On Being a Therapist by Jeffrey Kottler. Did you ever read that? Do you know what I’m talking about?
Dr. Jessica: Bits and pieces, but I can’t confess to have read the whole thing.
Dr. Sharp: Yeah. Honestly, I don’t remember anything about the book except for this story where he tells a story about a patient that he was treating who he conceptualized as having basically treatment resistance. The guy just wouldn’t engage in treatment, he wouldn’t do his homework, he wasn’t improving; his depression was not improving over weeks or months or whatever it may have been. And so the guy eventually stopped coming to therapy.
And Kottler in the book says [00:43:00] that he felt pretty confident that eventually, the guy would figure out that he was ready to do the work and he would return to therapy. And so he gets a call from the guy, say six months after they ended treatment, and in his mind, he is like, okay, here it comes. He’s ready to come back and do the work.
Dr. Jessica: I finally won him over to my side.
Dr. Sharp: Yeah. And the guy calls and he’s like, “Hey, I just wanted to update you and let you know they found this particular species of mold in my house that’s been causing my depression all these years and I feel great now. They removed the mold and it’s amazing”. And Kottler was just like, oh my gosh. We get this mindset of we know what’s going on and it could be something completely different.
Dr. Jessica: Sure. Totally out there. What a wild story that is. No wonder it stuck out to him. He wanted to put it in the book.
Dr. Sharp: Yes. Let me see, I want to move to the assessment component, that’s really interesting. [00:44:00] Before we do that, could you speak just quickly, I’ll pull this one point from your class back in the fall around medication response when we’ve got an ID and ADHD going on. Can you just talk about that for a second before we transition?
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Dr. Jessica: Sure. [00:45:00] Just to be clear, there haven’t been a ton of studies on medication responsiveness, and when I’m referring to medication, I’m really referring to stimulant medication, which is oftentimes the first line of treatment for ADHD. You can argue whether it should be, but most times those first-line treatments, and certainly in the medication world, most people start with a stimulant.
And what we see is that when looking at individuals who do meet criteria for both ID and ADHD, so this is a comorbid presentation, there might be some differences in their responsiveness to medication and so to stimulant medication, with those with an intellectual disability and co-occurring ADHD being less responsive to medication and then also reporting more side effects.
That really is interesting to me.[00:46:00] I don’t know that I can answer the question of why, I might be able to speculate. But I would want to be clear that it is speculation as opposed to having a more well-researched answer. I think it’s also possible that as folks with ID get included in more medication research trials, that statement or at least certainty of that statement may change over time. But it’s interesting.
I would want to encourage people to just have that as a point of note. We wouldn’t ever want to say to a client or to the caregivers of a client, ah, this is less likely to work for this individual or this individual it’s more likely to have side effects. I don’t think we can say that conclusively at all. But I do think it’s something that we should be thinking about, [00:47:00] maybe asking about more consistently knowing that it’s a possibility.
Dr. Sharp: That’s fair. I’m totally fine with speculation if you want to speculate a little bit about why the differences.
Dr. Jessica: Yeah. Well, I won’t be able to speculate at a biological or a physiological level, that’s really outside my competency. But I think, really with stimulant medication, what we see is that it does help people show more behavioral inhibition. And depending on how you’re measuring it, maybe sustain attention for longer than they did previously.
Now, when you have a person with co-occurring ID and ADHD, those folks tend to [00:48:00] have more severity of presentation overall. They have more areas where they’re experiencing struggle than somebody with ADHD alone.
And so I don’t think that we can discount caregiver attribution. And so if somebody really is maybe hopeful that this medication is going to help, it may help in the ways it’s designed to help, but it’s not going to alleviate all dysfunction or suddenly make somebody adaptive to their environment in ways they weren’t before if those skills haven’t also been concurrently taught. So it may be just in general, you have a person with a broader range of needs that medication alone was never going to treat.
As far as the more side effects, that one is really interesting to me and where I really get speculative. I don’t know if you remember from that [00:49:00] class, and I’m again speaking outside of ID and ADHD, but we did have a class on ID and depression. And specifically, there have been some studies that have documented that folks with ID or other developmental disabilities are reporting more symptoms of things like premenstrual dysphoric disorder, pain, et cetera, that it persists longer.
And so there’s a real question of, is this perception or is this real and how do you disentangle the two? But it’s notable to me that folks with co-occurring ID and ADHD, there have been a small number of studies that say, hey, maybe there are legit more side effects experienced by these folks. And then in other areas of literature saying, hey, there’s more symptoms of other things occurring and happening at a more severe level.
So I think in the absence of being able to say [00:50:00] why we have to be really respectful when we have side effects reported, and consider them as very meaningful to the person that is reporting them, and keep in mind that this may be at a physiological level landing differently, for lack of better word, that medication is having a different effect on certain individuals than it is others.
Dr. Sharp: Yeah. That’s fair. We’ll let the speculation be…
Dr. Jessica: Around.
Dr. Sharp: We’ll let it exist and see where it goes. Thanks for hypothesizing a little bit.
Let’s transition to the assessment component though. I might ask some fairly pointed questions I suppose about the assessment side. We’ve talked a bit about assessment. We’ve talked a lot [00:51:00] about assessment on this podcast in previous episodes. I think we all generally know when we’re assessing for ID, it’s a combination of cognitive assessment and adaptive functioning assessment. So I’m curious for you on the adaptive side, everything that you might be doing to assess adaptive functioning outside of the typical, Vineland, ABAS. It seems like those are the big two, but I know that you talked about other options and so I would love to shine a light on some of those options.
Dr. Jessica: Sure. Well, and before maybe talking about some specifics, I do want to maybe mention some generalities. So one thing we know from the literature is that when you have this combo of ADHD and ID, and I was starting to allude to this earlier, but oftentimes those individuals are going to [00:52:00] experience more impairment in life functioning than either ID alone or ADHD alone. And oftentimes, this is referred to clinically or in some research studies as a double deficit. So the scope and magnitude of the impairment or lack of adaptive skills is another way of saying it is greater than if you’re looking at either diagnosis or isolation.
And when you think about that breadth of impairment or where you see that impairment, there are some areas that I want to highlight. And some of these areas are absolutely covered in some of those really fantastic tools you mentioned, like the vineland, for example. But I think it’s worth also exploring with caregivers and with a client themselves, where else or to what degree or in what specific settings or what specific situations they’re also experiencing [00:53:00] troubles or concerns. But broadly, one of the areas of assessment or one of the areas of impairment that we should be assessing are the areas of judgment and reasoning in memory. So certainly, those are not exhaustive of what we call executive functioning, but they are related to areas of executive functioning.
Family conflict is another area that we should really be assessing for, particularly when we suspect there is this co-occurrence. We should do that regardless but in particular, when there’s this co-occurrence of ID and ADHD, there is a high level or likely a high level of conflict within the family because it is hard to take folks and put them in a caregiving role when they have no previous experience or knowledge in how to best mitigate [00:54:00] really difficult situations and teach behaviors and maintain behaviors when they’re coming into this without any prior training.
And so it’s really common for what we would call coercive patterns and families to emerge because the client and the caregiver are mutually reinforcing each other and doing what they need to do to get an outcome. And sometimes those outcomes are a little short-sighted or maybe not as conducive to long-term adaptive skill-building that we would want.
Another area is really social skills deficits. So people with ID and ADHD oftentimes experience, and I know this is such a global thing to say, social skill steps, but that comprises a lot of different behaviors [00:55:00] and skillsets. So not only like social knowledge, knowing what to do in situations but knowing how to interact with same-age peers in a way that doesn’t make them particularly vulnerable to being exploited. Being able to act flexibly as social situations change. Being able to shift their responsiveness depending on who’s in the environment and what’s being asked for in the environment. Like that’s a lot of little skills in there. And really getting a more nuanced sense of what is contributing to these social skills deficits is really important for folks to do.
Same thing with academic difficulties. That can mean a whole bunch of different things from, are they having difficulty attending to what a teacher is saying to is the information too abstract for [00:56:00] them to understand and they need it to be made more concrete, to are they having a translation difficulty from idea to application?
I know I’m touching on all of these really fast and we could have whole episodes about each of these, but the last big one that I want to mention is getting more of a sense about any behavior problems that are happening. So this could be like defiance all the way to aggressive or violent behavior to bullying others or being a recipient victim of bullying to fill in the blank. There are a number of different behavior problems that we should be assessing for.
And absolutely, the tools that you mentioned before are useful tools for really getting both some specific [00:57:00] behaviors and also larger domains of like, this is an area of adaptive functioning that’s difficult for this person or problematic for this person. But I think where we can really bring our skillsets in is with the when, the why, how really starting to get a sense of what are the antecedents and the consequences and the environment they’re influencing the expression of these problems.
Dr. Sharp: Yeah. It’s a nice transition actually. I wanted to ask you about the role of, y’all called it functional behavior assessment in this whole process, right? Like typically, I see FBAs happening in the schools. I don’t see a lot of FBAs in private practice assessment. And I’m curious if you see it the same way, or if there are ways that we can do more of an FBA in private practice.
Dr. Jessica: That’s a great question. I [00:58:00] often see it in schools because many times it’s done in the context of creating an individualized education plan or when the kids having behavior problems in school, oftentimes schools will develop something called a behavior intervention plan or a BIP. And so these functional assessments of behaviors are a requirement often for both of those, which is why they’re done in schools.
I’ve seen huge variability in how informative or nuanced or helpful they are. But really functional assessment of behavior is something that I would love to see done more as part of clinical interviewing. Whether we’re doing a diagnostic assessment or just a broader assessment to know what kind of treatment to start to provide [00:59:00] for a client, I think it’s hugely informative.
I like to do it with the client and with the caregiver to make it a visual and collaborative process. So I may have to modify and I should be modifying the vocabulary that I’m using. So some families are like, “Yep, we get what an antecedent is, let’s go from there”. But for other families, I might say scratch out the word antecedent and write in the word before.
So this is the behavior that you’re struggling with. This is the behavior that’s causing problems in your relationship or causing problems in home setting. Can you think of a time when that behavior happened recently and then I’ll see, it oftentimes helps if they can have a specific instance in [01:00:00] mind or visualization in mind. And then I’ll ask them like, what was happening before? Was something being asked of the kid? Were you in a situation where there were demands put on the kid? Just give me as much information as you can as the before.
And to be fair, sometimes caregivers are like, “I don’t know. It seems like a typical day. Seems like this is always happening.” And I think that’s a really fair and common response, in which case I’ll say, okay, tell me all the types of situations you can think of where he’ll do this problematic behavior. And I’ll start to think, does it happen at home? School? With peers? Other settings? Does it happen in church? Does it happen at Boy Scouts? Does it happen with grandmother? So I’m trying to get a sense of like, is it happening with multiple people across multiple settings, or is it seeming to happen more often [01:01:00] in one type of setting, or when one type of demand is being put on them, or with one type of person.
And then I really ask parents to define the problem behavior. What I mean by that, it says, how do you know when you see it? So not just he’s having a bad attitude, but what types of things is this kid doing that mean a bad attitude to you? Is it the eye roll, is it the walking away from you, or is it saying no to whatever you ask of them? I try to get them to be specific and then I say to them, what would you like to see? What’s the behavior that you would rather have happen?
And that’s always really, of this whole thing, probably one of the most important pieces is that caregivers or teacher, whoever is I’m working with, [01:02:00] they just want this uncomfortable or aversive behavior to stop. They want it to go away. But oftentimes, there’s some difficulty in describing, well, what is it that I would like this kid to do instead? Or what I would like this young adult to do instead. And that’s really where I feel like you can get some important information about what is this adaptive skill that we’d rather see in place of this other behavior.
And that gives us a lot of insight into: How could I teach the skill? How could I teach the skill to the caregivers? Does this inform a treatment goal? If acquiring the skill would help with this larger domain of adaptive functioning, that’s likely something I should be doing. And then the follow-up questions I ask are, okay, so when the problem behavior or the undesired behavior happens, what usually happens right after?
And so, I try to assess both [01:03:00] short-term and long-term consequences. So the kid does something and they get yelled at. A lot of families are like, I’m doing something aversive. I’m doing punishment. I’m yelling at them and they’re still doing it. And what I hear is, okay, behavior gets a reaction from the parent, doesn’t matter if the reaction’s, good, bad, or otherwise, but it’s still a reaction.
And then I try to ask them like, over time, is that behavior happening more, happening at the same rate, happening less? What do you worry about in the long term? And then I ask those same types of questions with the desired behavior. Okay, if you’d rather the kid do this, when that happens, what are you doing afterward? I’m trying to use simple language to get at what are the antecedents, the consequences, the [01:04:00] maintaining consequences of both the problem behavior and the desired behavior.
And then the last piece is I try to take a guess as to what function is maintaining this behavior and really broadly, this comes from the behavior analysis field, but there are like four reasons why behaviors happen. They’re often referred to as functions, but those reasons why, and again, we don’t always get our guesses right, but many times we can launch out a hypothesis that we can then explore, but it’s like to get attention, like in that example I just used, if you do something and it always gets your reaction, even if it’s not a great reaction, it’s still attention. So I might say, well, how can I give attention when something more desirable happens and start to produce attention when these undesirable behaviors happen?
The other functions are [01:05:00] to avoid or escape something. So to get out of something that feels aversive or to keep away from that thing that’s likely to be aversive, to acquire something, to get something. So that could be, get a snack, get a reward, get a toy. So it could be tangible or intangible, but to get at something. Or then the last category is what we call automatic reinforcing. People do things because they feel good so why is somebody rubbing their fingers? Maybe it just feels good to them. And so it is in and of itself automatically reinforcing.
But that’s my guess as the clinician and that helps me to drive some skill-building treatment plans but the rest of it that I’m doing with the family helps them to start to tape these really messy, frustrating situations that they are encountering with their kid and start [01:06:00] to make them less messy. Start to help them make a little bit of sense of like; maybe are there patterns here that I couldn’t see before? So I think that was a really long-winded way of saying, yeah, I find them really useful.
Dr. Sharp: Right. Well and appreciate you spelling out your process for doing it. I think that’s helpful. Anything practical is helpful. If we did want to go the route of more standardized measures or questionnaires or whatever you might call it, what else are you pulling out of your pocket for adaptive functioning assessment?
Dr. Jessica: Well, just to clarify, are you asking me about adaptive functioning specifically or what I think about assessing for ID and I think about assessing for ADHD and I think about the big picture the assessment of both? I just want to make sure [01:07:00] I’m answering or I can hit it both if you want to.
Dr. Sharp: Maybe we do tackle both. I was thinking with that question just specifically with adaptive functioning, but I would love to hear your preferred overall battery as well if we could go there next.
Dr. Jessica: Yeah. Well, so for adaptive functioning, we mentioned two, but there are really four that you would say have, and you’ve probably heard of many of them, but have sound psychometric properties and we can use consistently and feel good that the information that it’s giving us is valid, accurate information, stable information.
The first is the Woodcock-Johnson Scale of Independent Behavior. So this is a report form. It can be used [01:08:00] with clients with a really wide age range. So from ages 3-80, there are three scales that you could use depending on what your current need is. There’s a short form, there’s a full scale, and then there’s an early developmental scale. So depending on what your particular question is, you may choose to use one of those particular scales. And really what the purpose of the Woodcock-Johnson Scale of Independent Behavior is, is to assess for functional independence and adaptive functioning across a number of settings. So across school, home, workplace, and the community.
Another specific tool that is often used and has good psychometrics is the Vineland Adaptive Behavior Scale. I think that’s probably one that most people are familiar with. It’s normed from birth through age 90. [01:09:00] So a huge age range, huge applicability. It has both a parent form or caregiver form, and then also a teacher form. Now, you’re not going to use a teacher form with the 88-year-old, but you’re matching based on the setting that the client is in. And it really focuses on three areas; communication, daily living, and socialization. There are a few more than that, but those are some areas of emphasis that are really important to assess for ID and are also really useful to assess for ADHD as well.
Another is the Diagnostic Adaptive Behavior Scale. So this is from about age four, up through early adulthood, like 21-ish. It has three broad areas that it’s assessing; conceptual, social, and practical functioning. [01:10:00] And many people like this scale. So even though the age range is smaller, it has support, well let me say this, it has cutoffs that can be helpful for making a diagnosis. And so many people like this scale for that reason. So it helps to determine the types and intensities of supports that are needed, as well as giving these rough cutoffs that one can consider for diagnosis.
And then the last is something called the Supports Intensity Scale. So this is for folks 16 years old and older, and it really is specific to helping to determine what type and what intensity of support is needed for the individual that you’re working with. So oftentimes this is used in combination with something like the diagnostic Adaptive Behavior Scale.
So really when [01:11:00] thinking about just adaptive functioning broadly, and then I’m also in the back of my mind thinking, adaptive functioning for somebody with ID, adaptive functioning for somebody with ADHD, these are some really useful ones.
You mentioned some others like the ABLE Adaptive Skills Checklist, the Adaptive Behavior Functional Checklist. There’s one other that I really like. This is a form that was developed specifically initially for kids with ADHD. And now there’s adolescent version, the young kids’ version. But it’s called the Impairment Rating Scale. And the reason why I like the Impairment Rating Scale is because it’s been very well validated in folks with ADHD. And it’s also an open resource scale, meaning …
Dr. Sharp: That’s great.
Dr. Jessica: Yay. Yeah. There’s no charge for using it. [01:12:00] But with the Impairment Rating Scale, it allows the respondent, so there’s a kid version and then also a caregiver version to rate on a Likert scale from no problem, definitely doesn’t need treatment or special services all the way up to the other end of the scale with the anchor of an extreme problem definitely needs treatment or special services.
And then there’s an overlay that the clinician puts on there, divides the Likert scale up into units. And we generally say anything like a four or above is clinically important. But it assesses six different areas. One being, what’s this person’s relationship like with peers and siblings, or if it’s the teacher form, peers, and classmates? What’s the relationship like with the parents? For the teacher form, what’s the relationship like with teachers? The academic progress of a person [01:13:00] or if they’re moving into adolescents or young adulthood, occupational progress or functioning parent form, the family in general, teacher form, the classroom in general, the client’s self-esteem, and then their overall need for treatment.
So in addition to that Likert scale, there’s also a text box available for the respondent to fill in any open-ended information that would be really helpful. And I find that really useful to have both; that quantifiable metric and then also the qualitative information that the respondent is providing. And so you can just not only know, like, yeah, they’re struggling with their peers but the respondent let me know that they’re quick to make friends but lose them easily. They don’t have a best friend identified or whatever else narrative that person provided can give some really contextually rich information that’s helpful [01:14:00] for me to know what is their adaptive functioning socially or what are some areas that we should really target in treatment?
Dr. Sharp: That’s great.
Dr. Jessica: I’m a big fan of that, but I do want to be fair and say that I don’t know if studies that have looked at the Impairment Rating Scale’s specific to intellectual disabilities. So I think certainly those areas are important, but they may not be sufficient. So I might use this in conjunction with something else.
Dr. Sharp: Fair enough. How about the broader battery with ADHD and ID taking?
Dr. Jessica: Sure. So when I think big picture, and I’ll get to some specific recommendations in a second, but big picture, when I’m thinking about assessing intellectual disabilities, there are five or six areas that I’m going to cover. So the first, of course, has to be [01:15:00] cognitive functioning. That’s a necessary component of making a diagnosis. And then the second, of course, is also going to be adaptive functioning or impairment. The second necessary part of making a diagnosis. So those are always going to be in there.
In addition to that, I’m going to get a developmental history. So I want to know about age onset when in development we start to notice concerns, and in what ways were those concerns noticed? If possible, I want to do that functional assessment. So what I was describing to you earlier is really informative for folks with an intellectual disability, knowing when, how, maybe even possible, and why certain behaviors are happening or certain skills are lacking. ere’s a lot at a moment-to-moment level that can be [01:16:00] gained from those functional assessments.
I am going to assess for comorbidity and comorbidity of mental health concerns. So not just ADHD, but mental health concerns more broadly, knowing that this has been an under-recognized area, but contributes to a lot of strain for these individuals and for their families. I want to make sure that’s a necessary component of what I’m doing.
And then for me, time permitting, I might also do something called a preference assessment, which is where I’m trying to figure out if I’m going to be teaching skills to this person, what they most want to work for. And so there are a number of different preference assessments available. But that one I usually save for last time permitting, or maybe it gets, brought into some subsequent sessions. So those are big-picture areas.
For ADHD, I’m going to look at ADHD symptom presence and severity. I don’t [01:17:00] necessarily have to look at cognitive functioning. I know many people do. I know I often do. It can be informative, but it’s not a necessary component. So that may or may not be in there depending on what else I’m learning about the client. But I am absolutely in addition to that symptom presence and severity, also going to look at impairment or adaptive functioning, that’s a necessary component of that. And that echoes what I would be doing anyway with an ID assessment.
I’m going to include a functional assessment. When, why, and in what contexts are certain behaviors happening? I’m going to look at that developmental history, the age of onset or where in development did you start to notice these behaviors or these symptoms are different than other kids or are causing problems or impairment? And I’m absolutely going to assess for comorbidity because if we know anything about ADHD as that, it’s more likely to [01:18:00] co-occur with something else than it is to be the sole explanation.
So just in those broad areas, you can see there is more overlap than there is difference between those kinds of categorical areas we’re going to assess. So if I, throughout the course of my assessment started to suspect there is also ID happening or is there also ADHD happening, what I would probably do is the following: I would do an assessment of cognitive functioning. So for those that aren’t trained, you’d have to refer to a psychologist or neuropsychologist. But you generally really use something like the WISC, Stanford-Binet. If our clients aren’t verbal, of course, we’re going to use a different cognitive assessment.
Broadly, I want to get an assessment of cognitive functioning. I want to get an assessment of adaptive functioning. So I’m going to use [01:19:00] something like the Vineland and or that Impairment Rating Scale that I made mention of. I’m going to want to assess for comorbidity. So I’m probably going to choose to give something like the CBCL, the Child Behavior Checklist, the BASC, the Behavior Assessment System for Children, the RCADS, the Revised Child Adolescent Depression Scale, some kind of screening of comorbid mental health functioning.
I’m also going to assess explicitly for DSM symptoms of ADHD and probably to do that efficiently, I’m just going to give a checklist, but I might also do that in the form of an interview as well. But the DBD checklist -Disruptive Behavior Disorders checklist is a really great one. The Vanderbilt or the SNAP are really great ones. You may get enough information from the BASC or maybe the CBCL that you don’t have to also do that, but generally, when I’m suspecting ADHD, [01:20:00] I want to make sure I have a good accounting of the behavioral symptoms, the diagnostic symptoms of ADHD.
I’m going to do that functional assessment of behavior, so I can do an antecedent-behavior consequence form. And I’m realizing you have a copy of what I went over in the training, but I also am happy to email some of the things I’m referring to, like that functional assessment that I talked through in the interview form. I can send that your way if you want to post it for your listeners or the Impairment Rating Scale.
And then lastly, for preference assessment, I’d probably do something, there’s a number of different ones, but the Choice Assessment Scale is one that I find useful. So that’s if I had to conceive of a battery that would really hit on both of these areas and help me to assess both of these diagnoses, that’s what my battery would look like.
Dr. Sharp: Great. [01:21:00] Yeah, practicalities and concrete strategies are always good. And there are so many questions about what battery people administer. There’s always questions. I always make sure to ask when the opportunity comes up.
Well, I know that we’ve covered a lot of ground and I appreciate you digging in so deeply to each of these stacks involved here, the background and then some of the more practical assessment. Is there anything that you’d like to leave us with? Either it could be resources, could be just general thoughts or philosophy around this topic. Folks want to learn more or incorporate this into their practice.
Dr. Jessica: We’ve talked a lot about assessment and as the nature of [01:22:00] this podcast calls for, but really I look at assessment as oftentimes for insurance purposes, something you have to identify diagnosis first and foremost to justify treatment. But beyond that assessment should be an ongoing process and a process that’s really helping us to identify, is my client improving or developing skills in the areas that we’ve identified as of the greatest need for them to do so. And so assessment really should be conceived of as this ongoing process.
And then when it comes to treatment, I think both for ADHD and for ID and certainly the combo of the two. If I could impart two helpful things, it’s that focusing [01:23:00] on skill building and skill application is far more useful and beneficial to the client than just trying to do symptom amelioration or reducing symptom severity. We find way more benefit for folks when they have gained or been able to apply skills that they hadn’t before. And so really taking that skill lens in treatment is helpful.
And then the second thing that I would say that goes along with that is really looking at point of performance feedback. By that I mean, teaching a skill, giving the client the opportunity to rehearse the skill, practice the skill, or apply the skill in setting, and then giving them point of performance feedback. So instead of [01:24:00] waiting till the end and saying, that was great, now go try that at school. As they’re doing something saying that right there was a really nice way of sharing with me. That made me feel great and I appreciate that. I’m going to share right back with you. How did that go?
So really as the actual behaviors emerge, providing either corrective feedback, if it was something that was implemented in a poor, clumsy or missed the bone boat way, and then when it is implemented in a way that you want to see more of really providing explicit feedback on, hey, you just did it. This was awesome. So that could be praise, that could be validation, that could be just be describing and reflecting what they did. But to me that is the essence of treatment, is this point of performance feedback as opposed to try and now go try to apply it somewhere else. But [01:25:00] really for like skill building in the moment.
Dr. Sharp: I think that’s such a good point, and that may be a nice note to wrap up on, just to leave people with, that in the moment feedback, I think it goes a long way compared to just theoretical, hey, let’s talk about this in session, go out, practice it, unless they’re deliberately going out to practice, which is hard to do when it’s an interpersonal component or something that requires another person to be on board. That’s challenging. I like to highlight that.
Dr. Jessica: Great. I hope that lands with some other folks as well.
Dr. Sharp: Yeah. Well, I think a lot of what we talked about is going to land with folks. Honestly, it was action packed today.
Dr. Jessica: Yeah. I warned you. I was a talker. I did warn you.
Dr. Sharp: It’s good. There’s so [01:26:00] many notes and resources that I think folks can take away. It’s what this is about.
Well, thanks for being here. Thanks for coming on to chat. And who knows, maybe we’ll do round two about this ADHD summit.
Dr. Jessica: Yeah. That’d be awesome. I’d love to do that. And you thank me. You’re absolutely welcome. But I want to thank you too. This has been a pleasure. I’m really grateful to talk about this. I think this is important stuff to talk about. I hope it’s really useful to your listeners and I’m just really grateful to you to have the opportunity to be here.
Dr. Sharp: Anytime.
Dr. Jessica: Awesome.
Dr. Sharp: All right, y’all, thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.
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