Signature Forums: Dr. Martha Denckla

Uploaded by TowsonUniversity on 22.01.2013

>>: MUSIC.
>>: Dr Nancy Grasmick: Here is a woman who just has a resume that
doesn't end, and who has saved so many children by way of her
diagnostic work with those children, her interaction with
the schools, with educators.
And I am much richer as an educator because I've had this
association with Dr Martha Denckla.
Please join me in welcoming her to Towson University.
>>Dr Martha Denckla: Well, needless to say, nobody should
ever accept an invitation to talk after Ben Carson.
>>Dr Martha Denckla: And, you know, actually, it made me think
of one anecdote.
He of course has saved many lives and I'm in a field - I'm
in this funny little corner of neurology where it intersects
with psychology and education, etc. And I think those of you
who are parents will appreciate this story.
I'm glad you said something about saving children.
My middle son went to Columbia and was on the train coming home
for first winter break when he was a freshman.
Came home to - I live in Bethesda, still do after 25
years working in Baltimore, but that's another story.
But at any rate, when you have children who are doing well in a
certain school system you don't move.
That the real - So, what's up?
Oh, thank you.
So, he was sitting there, of course, I have a very odd last
name, it's my married name.
And the boys who are coming home from college didn't know each
They exchanged names and when this other young student heard
my name he said, "Oh your mother, your mother's the
neurologist right?"
And my son said, "Yes."
And then he said, "Your mother saved my life."
And my son broke into, you know, ridiculing type of laughter.
And says, "Oh, no."
He says, "My mother doesn't do anything physical to people.
She hasn't saved anyone's life since she was an intern."
What he meant was that I had evaluated him and found that he
had terrible developmental dysgraphia and I had all the
documentary testing that showed that this was really a central
nervous system problem.
And so, I had said, "Forget the writing except for numbers,
because we don't have any word processing for writing our math,
and let him do the rest of his high school career with word
And in the eyes of this young man, that saved his life.
So, it's interesting, there's such a thing as quality-of-life
and that's what I've been privileged to be working on for
so many years.
I've been doing the traditional three-part academic career.
That means I've always been a salary doctor at three different
universities with a little interlude at the NIH, which
means that I've always have one day a week - and only one day a
week - to see children with learning and attention problems,
and the rest of the time, I've been doing research and, of
course, in the process of that mentoring and teaching
younger people.
And for the last three years, I've also been
teaching teachers.
I got very assertive and I marched myself over to the Johns
Hopkins School of Ed, and I said, "I want to teach teachers
about the brain."
So, that's my - that's my career stage right now.
Just using what I've learned over the preceding three
So, what I want to talk to you about today is - I'm so grateful
to Dr Carson for having mentioned executive function.
I want to talk to you about executive attention and its
impact on reading.
Was that my first one?
Okay we have this entity - how many people here have
heard of ADHD?
>> Dr Martha Denckla: Yes, okay.
And a lot of people - right off the bat; I want to explain that
ADD is not an officially sanctioned term.
We all use it, but it's actually ADHD with a comma and then you
have to say, "Predominantly inattentive".
But anyway, we keep saying, "ADHD" just because that's the
official umbrella and ADHD is a genuine condition.
That's one of the things I want to get across.
Lots of people in my social life will come up to me and say, "Is
this a real thing?
Isn't it just a fad, or isn't it just bad parenting?"
And I do agree that it's better to think of a lot of people as
being at risk for ADHD and if they get the optimal environment
they may not have any impairment.
But, if they get anything far from optimal, even in some cases
adequate, they will show manifestations.
We've done a lot of research over the past 25 years because
we've had MRI.
When you see the little A in front of MRI it means anatomical
MRI - and I just want to tell you since Dr Carson set things
up - that we have evidence for actual smaller or thinner lobes
of the brain in the frontal lobe, also in the basal ganglia
and the cerebellum has now come in.
All of these have - different chunks of brain - have been
found to be under endowed in children with ADHD.
And also, with functional MRI we found that the basal ganglia are
under activated and that the medication - the formal name
methylphenidate is the chemical name for Ritalin - actually
works through the basal ganglia.
So, I just want to give you an idea that there's a lot of
science here and our own group has shown that the shapes of the
caudate and its next-door neighbor, which is more of a
motor structure, are differently oddly compressed.
But basically, the bottom line is that these boys with ADHD
have less tissue in these parts of the brain.
And actually, I'll tell you, but I couldn't make a slide of this
because I just found out this morning - we have been trying
for years to find something with girls with ADHD in the same
elementary school age group.
We finally have some findings in the frontal lobe with girls with
And this means, really for 20 years we've been trying to find
something, so we finally found something.
The boys are much easier to find something deviant about.
But -
>>Dr Martha Denckla: No, I mean different from their peers.
I don't mean deviant in some other way.
Okay, so it shows -- however, what's very encouraging is that
fMRI does show normal sensitivity to rewards in
children with ADHD.
That's not true of conduct disorder and I think people over
identify ADHD as being bad kids.
So, I want to make it very clear that that's not what we mean by
But, you really can get plenty of good results if you hit those
rewards or pleasures, as Dr Carson was saying, with children
with ADHD and it's a very major, major important thing to know
about them.
Now, also medication is not a bad thing.
It's not a cure, but it's not a curse, because a group at the
NIH that's been able to do anatomical imaging year, after
year, after year has been able to show that the cortical
thickness is closer to typically developing peers when you treat
them, than when you have children whose parents refuse to
allow them to be treated.
It doesn't mean that it makes them normal, but they are a lot
closer to normal if they have had medication.
That's not because medication directly worked on the brain,
it's because medication made the children available for
experiences that made all of those repeated connections Dr
Carson was talking about.
So, if you get your foot in the door with this medication, you
then have the ability to sculpt the brain.
In other words, to get those neurons that fire together to
wire together and therefore, the brain looks much more like that
of typically developing peers.
Also, we have some good news.
Uncomplicated ADHD probably is a developmental lag.
You know, we do a lot of talking about developmental delay, but
that's really just a description.
We really just don't know whether some people are going to
catch up, but we have some evidence of catch-up in the
brain of children with ADHD.
However, it's about a three year lag.
So, what I'd like to leave you with is the optimism that they
may catch up.
But, the cortical thickness that their friends have in the second
grade, they don't get that until the fifth grade.
Now, if we start middle school in the sixth grade, which I
could spend the whole rest of my time telling you how we do
everything prematurely in education, but certainly we're
throwing - we're taking kids who have just gotten the second
grade level of frontal lobes and then we're sending them to
middle school when they've barely - it would be like, you
know, somebody who's just barely started to walk and we've
decided that they have to go try out for the baseball team.
So, we are - we are not taking our data about the underlying
physical lags and using it appropriately.
So, we have a lot of reason to believe that most children with
uncomplicated ADHD - what I mean by uncomplicated is that it was
just something that happened because of some genetic pattern
of development.
Someday, I think it might even be like when you get your second
teeth, you know.
I mean, how many people here were relatively late in their
second teeth?
Do you know?
I know I was.
For example, I got my wisdom teeth - they came in when all my
friends were having theirs pulled out.
So, you know - that's a - I was on a very - and one reason why
I'm no longer as tall as I used to be - with age - the reason I
was a very - I was in 99th percentile height was because I
had very late puberty, also.
So, there are a lot of timing events in our physical genetic
code that will lead - in some cases it's not - I mean, I
didn't like being as tall as I was, but it wasn't exactly a
tremendous handicap, nor was the fact that my wisdom teeth came
in when I was 19 or something.
But, if your frontal lobes come in three years later than
everybody else, even though you are normal after that, you have
already been at a tremendous disadvantage for many, many
years of your life because when you were in preschool, you were
a terror and maybe you settled down physically and you were not
a terror anymore in elementary school, but you were not able to
concentrate, and to plan, and to manage your time and do all
these things that other people could do because they had the
brain structural and brain connection basis of the things
they were asked to do.
I'm going to skip some of these.
Now, what is executive function?
We first began to look at executive function because we
knew from adult neurology that the frontal lobes were very
And we also saw with our imaging that in ADHD, the frontal lobes
were very commonly not as well developed as they should be for
the age of the children with ADHD.
And there's a very important book by Barkley that explains
executive functions developmentally.
The first thing you see in the process of executive function is
Inhibition is simply the ability to not do something.
Now, that sounds crazy, like, why is that important?
Well, the wonderful researcher, named Adele Diamond, who shows
that if you put a teddy bear into a Plexiglas, completely
transparent box, and has an opening on one end.
You put it in front of a baby who can sit up.
Baby is six-months-old, seven-months-old,
eight-months-old - the baby will get very frustrated because the
baby can see the teddy bear through the transparent plastic
box and will keep on reaching for it, and the little hand will
bang up against this clear wall.
A wonderful, fantastic thing happens around nine months.
You'll see the little chubby hand go out and it kind of stops
in midair, and it begins to feel around on the box and discovers
there's an opening and it can get out the teddy bear.
But, you had to stop before you could explore.
If you just went reflex, reflex, reflex, I see it, I reach for
it, you could never develop a strategy.
So, inhibition, which comes in for the first time towards the
end of the first year of life and continues, and continues,
and continues, you have to be able to stop in order to look
and listen.
So, stop is very important.
It's very important in converting us from a reflex type
of creature into one who can reflect and explore.
So, that's very important.
You know something funny?
This is not what I - this presentation here is not the one
that I really wanted to - that I have here.
It's on a related topic.
But remember I sent you two things?
I'm going to see whether the other one is in here.
I'm sorry, but what I've got here planned to talk about and
what's on here is not the same thing.
But, I'll just have to - I'll have to adjust to that.
We made a choice and we got - this is - we don't have the one
that we really wanted, because the one that I wanted was going
to be much more zooming in on reading.
But, I'm going to just have to go with what I have here because
I think otherwise you're going to get too confused.
So, what we've set up is executive function starts off
with inhibition, but it's not just inhibition.
It's also processing speed -- very important thing that
teachers deal with all the time and what we now call the motor
end of phenotype.
The writing problems are very common with kids with ADHD.
But it's very important for teachers to recognize that
although it sounds like you're contradicting yourself,
especially if you leave that word 'hyperactive' in there -
most kids with ADHD are slow processors.
We don't quite understand this, but we have a lot of data
accumulating that processing speed is one of their tremendous
Now, is executive dysfunction actually diagnostic of ADHD?
It's not even - I get these phone calls all the time from my
clinic where people say, "I have been told my child has executive
function disorder."
I said, well that's nice, but it's not in the Diagnostic and
Statistical Manual.
There is ADHD, but there is no disorder called executive
It's not a diagnosis.
But it is the cognitive link between what we see about the
frontal lobe in these kids as researchers and what in the
classroom you're going to see as somebody who lacks efficiency as
a student.
This is why it's so important because every single aspect of
executive function is what runs the show for a person being a
successful student.
Think of it as all the things that are in the driver's seat
when you are in the car.
The child's intelligence is like everything that's under the hood
of the automobile.
That's all the potential of the vehicle.
But, the executive function is everything that you sit in that
driver seat and use that potential to go, to stop.
Again, think of inhibition as the breaks.
Think how important the breaks are to a car.
You know, if you ever try to drive a car that was showing
insufficient breaking power, you know, you can't take a corner
the way you want to.
You certainly are in danger if you can't stop what you need to.
So, the brakes are important, but also, the steering is
Also, knowing whether you should be going in -- if you have a
gear shift, it is very important to know what gear you should be
If weather conditions change, you have to plan to use the
appropriate windshield wipers or switch your flow of air so that
it defrosts your front window.
All of these things make the potential of that car into an
actual, useful vehicle.
So, a child who has a high IQ, who has everything under the
hood, has language skills, has perceptual skills, has memory
skills, but none of it is under control.
It's all kind of at the mercy of road conditions, so to speak.
It is going to a tremendous amount of trouble with almost
all school subjects.
So, executive dysfunction is not a diagnosis.
But in educator's terminology it is a set of processing problems.
It's not processing confined with specific content area.
Now, people however, sometimes are very talented in one thing.
So someone who is a tremendous natural at certain things can
get by with half an eye and half an ear and very little planning,
and very little strategy for quite a few years.
But if you're just average in your endowment you're going to
have to have all of these control and organizational
The executive function has to have a feed in from the back
part of the brain.
You have to have that part of the brain that was pointed out
to you as being the temporal lobes and the parietal lobes
sending all the good information and content to the frontal lobes
in order for it to be acted upon.
So certainly we have - and I've spent years researching dyslexia
- we have people who have weaknesses in some of the - what
we call the server areas from the back of the brain.
You can also think of it another way if you don't like car
analogies, you can think of executive function as being like
the recipe book, and the specific abilities and talents
that make up our IQ, or make up multiple IQs, if you like Howard
Gardner's model, as being the contents of our cupboards in our
But, if you don't have recipes, you may end up with a mess.
And my favorite image about dysexecutive people, of any age,
children or adults, is that they're the people who start
doing the things on the recipe without reading what all the
ingredients are.
So, when it gets to the point where it says, "Room temperature
butter," and you are running into the freezer and trying to
stick it in the microwave, just long enough to make it, you
know, and it ends up being, you know, butter that you could use
to sauté your vegetables in, but not room temperature.
That's the image of a person who is -- has lots of ingredients,
but does not follow a recipe and does not plan ahead.
Now, what do we see clinically?
We see problems with inhibit, sustain, initiate, and shift,
which conveniently spells "ISIS".
So, when I teach my residents, I can teach them, those are the
four, sort of gear shifts, basically of executive function.
You also see a lot of motoric immaturity.
If we had Doctor Carson's brain here, I'd show you the back end
of the frontal lobe is the motor part.
That is the most -- first one to develop after you're born and
it's the motor strip.
So, it's in the neighborhood, and the executive system is what
makes you be able to do very fancy things with your motor
So, you find that almost all of the children, who are in
elementary school anyway, are going to show motor problems and
handwriting is a very prominent one.
So, almost always that's another straw that breaks the camel's
Is that not only do they not have the good executive
function, from the more advanced part of the frontal lobe, but
the back end of the frontal lobe isn't terribly good, either.
And particularly for handwriting, which is an
extremely, extremely difficult neurological activity.
I'll tell you how you can -- I can always remember how this is
proven -- when I was in a resident neurology, we used to
do consults to the medical service.
They would call us all the time and say, "We think Mr Jones, who
is here for his liver, or he is here for his kidneys, he has had
-- we asked him to sign a consent form for a procedure and
he couldn't write his name.
We think he must have had a stroke."
Turned out not to be true.
That if a person was in renal failure -- that's kidney failure
-- or a person was in liver failure and toxicity was
affecting their brain, before anything else was obviously
wrong, they couldn't write anymore.
That's how delicate a function and how difficult a function
writing is, and I really want to impress that on people.
We just don't give it enough respect.
In fact, we don't teach it, we can also go off on a whole thing
about why we should be teaching cursive and not teaching
printing, a whole big -- and I'd be happy to entertain questions
about that, too, because I have very strong feelings about how
we do not respect both how difficult writing is, how much
it really would have to be learned, and also when we should
back off and wait for signs of maturity.
Obviously, executive function mainly means these fancier
things, like visual motor organization.
Like, if you give somebody a complex geometric figure to
copy, can they get it on the page so that it has some
resemblance to what they are copying?
Even if we've proved that they can perceive it, which we do by
multiple-choice testing, and lack of strategies or plan of
search, you can get a very bright child with ADHD, give
them a page, on which you just say, "I want you to find all of
the A's of the page, or all of the threes," Then you have
non-target letters and numbers, and they are arranged in rows.
Other children will go across like this.
Kids with ADHD will go plop, plop, plop, plop.
They don't tune into the structure being afforded to them
So, they jump, jump, jump, jump, jump all over the page.
It's just an amazing thing to see.
So, it's not intelligence, but it's a plan of search.
How am I going to do things?
And then, of course, time management, "When am I going to
do things?"
is another aspect.
Now, we put a lot of stock on assessing executive function in
younger children through the motor system.
We use the -- what I call, where there's smoke, there's fire.
I sincerely believe, if somebody will let me do this, that I
could go into a pre K, a four-year-old group, and I can
just tell you from the motor status who is at risk for ADHD
and how maybe we ought to think about how we do a behavior
management plan with that kid before the -- if we give them
enough rope to hang himself.
Which is, giving too much independence to a child who
can't handle it too young is really killing with kindness, or
that other metaphor, giving them enough rope to hang himself.
Because the motor system will hang out a little red flag that
says, "This frontal lobe and its interconnections is not maturing
at the same rate, not only as the rest of the class, but the
rest of the child."
And it becomes a really difficult thing for a child who
is perhaps, otherwise, very brilliant to cope with the fact
that he -- it's usually a he -- still four to one, boys to girls
-- that he cannot make things happen which he can perceive and
name and do lots of other things with, but the motor system is
not doing his or her bidding.
So, even without anyone else criticizing, that child is going
to have, already, a sense of frustration and possibly, if
they do get to school and have demands placed on them that they
are not ready to do, are going to decide that they, in school,
are not compatible with each other.
As Doctor Carson said, a child who is brilliant can still
decide because he can't put something on paper that he is a
And then you have a whole, huge cloud of the issue of negativity
about school, because you've asked the person to do something
he is not only not able to do, but doesn't live up to his own
We also have a wonderful -- if the child is at least eight
years old, and this goes from age 8 to age 80 -- we have
something called the Delise -- Caplan Executive Function
Edith Caplan was the person who trained me initially, and this
is a wonderful set of tests that will specifically address
executive function and is very sophisticated and it's awful lot
of fun to give.
The other thing is that people enjoy taking it, too.
It's very full of novelty.
So, actually, it's - you know, it's funny when I first started
doing assessments for ADHD kids in my clinic, I took some of the
research things, and a lot of them are these continuous
performance tests on computers, and they are like, push the
button when you see this, don't push when you see that, and they
would run 20 minutes at a time.
We got interesting research results, so I put them in the
The kids hated it so much, you could hear them going out the
door and saying, "I'm never going back to visit that Doctor
So, you begin to learn that there are certain tests that may
be very pure research instruments, but they are not
going to have much of a longevity in your office,
because if the consumer is that aversively conditioned by them,
you are not going to use them.
Now, you still need to have vigilance for language, because,
you know, basically, I could say two things to you, and say,
"What does it take to be a successful learner?"
Excellent language foundation and executive function.
Those are the two things you need to be a successful learner
in school.
I'm not saying in a successful learner for maybe things - I'm
trying to think of all the things we have to learn later in
Well, one thing for example, I have never learned, because I
have poor spatial abilities, parking a car in -- not in a
pull in space the way most of them are -- but parking on a New
York street, you know, estimating, "Do I have enough
room for my car?"
And getting it in.
I'm terrible at that.
So, one thing I would say is that I agree with Doctor Howard
Gardner's multiple intelligences, because a lot of
us have experiences that we have some piece of Doctor Gardner's
Lazy Susan, I call it, that we don't have much in
some of those trays.
>>Dr Martha Denckla: And, you know, it gives you a lot of
empathy with kids with learning disabilities, because if they
don't have much in the language tray, they're going to have a
heck of a time in school, and they may be much, much better
than you are at parking a car.
But, unfortunately, you know, they are not going to be in such
a position to laugh.
Another example, in my own life, is when I was eight years of
age; I was thrown out of a ballet class.
My mother was 4 foot 11.
I, in my prime, was 5' 10 ½".
So, even when I was a little girl, I was never a little girl.
I was always a head taller.
When I appeared in a play in the second grade, my father was
outraged to hear one lady whispering to the other, "Why
are they letting that retarded girl into this play?"
because I was so much bigger than everybody else.
But, so, I was not -- I was not endowed, first of all, I was
very right-left confused, and second of all, I was very
klutzy, and third of all, I stuck out like a sore thumb.
So, the ballet teacher told my mother she was not going to let
me come back anymore, because I did the wrong thing, going in
the wrong direction, and I was so large that I must've looked
like the Carol Burnett show or something.
You know, I was knocking everbody over.
>>Dr Martha Denckla: But, you see, we can all do enjoy a good
laugh about that.
But, what if that same missing ingredient were something to do
with a required school subject?
Other than my mother, kind of tsk-tsking at me, my mother
answer to everything was, "You didn't try hard enough, of
But, we can - we can survive that if we are not talented at
ballet or not a great athlete, but we do have people who have
lesser endowment, and I like to emphasize that a lot of the
things we do for school skills are really kind of like
specialized talents, and we somehow decide that everybody's
got to do them.
So, no wonder we have a certain percentage of people who are
struggling with them.
But, executive function is extremely important for
Going further in my own life, I actually got involved with
musical theater when I was in high school, and darned if I
couldn't learn to do all of those dance steps, when I was
motivated, as part of musical theater.
So, you can have a lack of talent, you may not be able to
do something as elegant as ballet, but you can work around
The same is true for many of our learning-disabled, but you have
to have that executive function.
You have to say, "Hmm I can't do ballet, but I bet you I could
do, you know, a little song and dance routine with my, you know,
one leg has to go in rhythm behind the other and in front,
you know, practice it and you can do it.
But, you have to have that executive function as a
compensatory mechanism.
I'm going to -- okay, sustaining and shifting, planning,
organizing and, something that you heard from Doctor Carson,
and I want you to reserve metacognition for that.
Remember when he said that the guy said that he was not good
enough for med school?
And he said, "I'm going to sit down and analyze my learning
That's Meta.
We should reserve Meta for that level, which is know thyself.
And too often, we throw around metacognition to below that
level and we leave nothing for that ultimate level, which is
you having this overview of yourself, and how you are going
to strategize to optimize what you need to do to succeed.
So, I just want to advertise, Meta applies to monitoring
yourself, checking on yourself, having insight, ultimately.
There are also implicit executive function deficits.
As I said, inhibition is the earliest one -- initiation,
because you got to get started, also, controlling your emotions,
setting your emotions aside in order to deal with a situation
where showing your emotions would sink the ship.
That's a very important kind of executive function.
I had a mentoring session which showed the opposite.
A young woman I'm mentoring in her earlier stages at Kennedy
Krieger, there's somebody else that was brought on board, who
is in her field, and she is very threatened.
And so, I said, "Let's sit and strategize.
You should invite her to lunch.
You should get to be friendly with her, you know.
You should see where you have common interests."
So, that would be using your executive function, not in an
inhibitory way, but in an actual strategizing, social way, that
you will set up a network with this person, where you both are
in a win-win situation.
So, you can see how very important the executive
functions are, and here is what I was alluding to.
I took Howard Gardner's Big Circle and it turned out
elliptical, because I couldn't make the program have it, you
know, it's meant to be like a Lazy Susan, that you have
nowadays mainly in Chinese restaurants.
And the executive function is like that mechanism that would
make all the different little compartments come around to
different people.
So, you look at all these different things, language;
symbolic, analytic -- very familiar for schooling -- two
kinds of visual perception; the 'where' system and the 'what'
Very interesting, we didn't know that until 25 years ago, that
your visual perception is not a lump sum.
That there is visual perception for where things are in relation
to each other, and then there is object perception, like
face recognition.
And I personally, I'm trying to drum up some interest.
I think this is where people are good spellers or not.
If they can learn to look at irregular words and say it looks
right or it doesn't look right, and I don't think it's been
investigated enough.
So, that's visual perception for a whole complex something.
And I just read an article this week that says the inferior
temporal lobe has a dedicated section for, sort of taking in a
visual object in a gulp, as a whole thing, and faces are the
prototype, but I bet you words, especially words that do not
yield to phonic analysis, are going to be another thing.
We have social interpersonal, like I was counseling this young
lady about.
We have a motor intelligence.
Doctor Carson couldn't be the brilliant surgeon he is if he
didn't have the kind of learning of motor skills he has.
It's a very important kind of intelligence.
That's why I'm not a neurosurgeon.
You don't want Sadie Klutz mucking around in your brain.
>>Dr Martha Denckla: So, and then there's - then there's this
Meta -- this Meta self and intrapersonal that we talked,
about knowing about yourself.
How do I work, what is my good -- what are my strengths?
And every woman who gets to her teens has this kind of knowledge
of her appearance, to know what's the best hairstyle, and
what colors are my good colors -- you have to do the same thing
with your brain function to analyze how your brain can be
Another thing that is very important, and I always like to
get this across in any lecture, auditory has three other
features other than what we say is auditory when we do
educational testing.
Speech sounds are in the left side of your brain, on the right
side of your brain.
In the same location, the temporal lobe, you've three
other things.
Music, -- people can be plus minus on music.
In identifying environmental sounds, knowing which is your
cell phone ring, knowing altogether whether it's a
doorbell, or a phone, or a dog barking, or whatever --that's
processed on the right side.
And tone of voice.
Is a person angry with me, is a person happy with me?
All of those things.
So, we have a lot of auditory that is not language and I think
we do people a disservice when we used imprecise vocabulary of
saying, "Oh, this child has an auditory perceptual problem."
because then -- I have actually had the experience of parents
coming in and saying, "Oh, my son loves music, but you know,
he has a reading problem and they told me that he has
auditory problems, so I don't let him take music lessons."
You just want to sink right through the floor when you hear
that, you know.
So, this is why knowing something about the brain has
some practical significance, is that you are condemning this kid
to not having music lessons, that might actually be his
career because he has problems with phonological, that is
speech sound issues.
So, this is why it's very important that there are all of
these different kinds of intelligence, but what allows
you to use them and to take them into action is your executive
function, which I said, is this huge frontal lobe that we have
and which some people are more slowly developing in than other
people, and this is the - this is the main point I'm trying to
make, is that we need to recognize who those people are
and -- I know that there are always, particularly fathers.
Fathers come to the office and say, "Well, he has to do this by
himself some time."
You know, and you say, "Yes."
You know, and you know, kids have to learn to cross the
street by themselves some time, but we generally don't let
two-year-olds do it.
We generally think of the concept of readiness.
Now, so we need to stretch that concept of readiness to -- and
this some time is not the same time for every single
So we, yes, we do have to do more supervision, structure, and
positive reinforcement for the people whose frontal lobes and
executive function based on those frontal lobe are lagging
behind the other kids.
And we have to think about our curriculum, not just in terms of
content and core, but how and when.
How and when?
And I know there is, because I hang out now with teachers all
the time, I know that there is this beautiful concept of
universal design.
We've got to mean that.
We've got to really mean universal design.
That, yes, we have our core curriculum, but we have, in a
given classroom, children who are at very, very different
developmental levels, even if they're not dyslexic or learning
disabled in the traditional way, this frontal lobe and executive
piece is so overlooked, and then we use these moral turpitude
words about it all the time.
We say, "You're in middle school.
You are supposed to take responsibility, you know, and
you are in charge," Yeah, but my brain is not ready to do that.
And that is, and then, of course, middle school being, of
course, on the brink of all of those wonderful hormonal things,
you know, we are also going to be in a lot of trouble.
I'm going to stop now and just tell you, since I started
talking about ADHD and I segued into saying executive function
is such an enormous, and I would say, long lasting lag, what
about stimulants?
One sentence; they're not a cure, they're not a curse.
Stimulants are helpful.
I like very much what one of my fellow teachers says,
"Stimulants help to make kids become reachable and teachable."
But, that's not the whole nine yards.
We individualize the medication for target symptoms.
It's very flexible.
It's an illustration of the art of medicine.
There is no right dose of a stimulant for a given person,
even at a given age.
I have some longtime followed up patients who took stimulants
pretty regularly when they were in elementary school, took it
Now they're in college and they take a stimulant dosage only
when they're studying for exams or writing a term paper.
Otherwise, they don't take it.
They take it the more or less the way the when I get black
coffee when I need to do my income tax.
You know, I mean, it really is quite analogous.
And, by the way, caffeine is a darn good stimulant.
You know why we don't use it much more?
What happens about 90 minutes after you drink coffee?
You got run to the bathroom.
It's a problem.
But the stimulants that are available in the pill form don't
have that same effect.
Caffeine has the virtue of being easy to buy and it's around,
etcetera, but you can only get about 90 minutes before you got
to go for the nearest bathroom.
So, it's not -- it's not very -- longevity to keep you
concentrating and sitting at your desk is not optimal.
I'm going to leave out some of these more medical things.
Even when we study large groups of kids, we find that if we
combine behavioral treatment with the pharmacological, we get
better results if people are oppositional or aggressive, if
they are depressed, if they have social skills problems, if they
have reading problems, and if they have parent-child problems,
in other words most of the time, combining.
Because the purer cases that are -- don't have any of these
problems are not, clinically, very numerous.
So, we like to combine it with behavioral interventions and the
most important one is a positively oriented behavior
modification program.
How many people here have had any training in what I am
calling positively oriented behavior modification?
Some people, a few people.
One of the best ways to do it is to get a dog and learn modern
dog training.
I'm telling you, it is fantastic to teach you the principles.
You know, we are no longer going around whacking dogs with the
newspaper and jerking on their neck and all that kind of stuff,
and it's really amazing.
So, the ABC of applied behavioral analysis, something I
think every classroom teacher needs to know for children in
general, but if you have some of these kids who are clearly so
immature, you can do so much good understanding the
principles of applied behavioral analysis and the ABC.
The A stands for antecedents that would be your universal
What am I going to ask this person to do?
Am I asking the person to do something that's at that
person's capability level, so that success can be achieved?
B is what the kid does, the behavior.
And C is the consequence and what we want to get across is we
want to skew the consequences towards the positive.
We want to try, as much as possible, to have, for instance,
if you divide up the day in a behavior contract and you have -
Instead of taking points away, just leave it blank.
You know, it's like when your mother said, "If you didn't have
anything nice to say, don't say anything."
We're trying to get the whole valence of consequences to be
either neutral or positive.
Neutral or positive because the brain releases dopamine with the
positive and that strengthens the learning connections.
So, I'm going to stop here.
And, is that okay Nancy?
We'll entertain questions.
Do you want to tell them?
If anybody wants this other one, I'll send it to you.
>> Dr Martha Denckla :The other one -- the other one was very
focused specifically on how this plays out in reading.
So, it has a lot of the same things but -
>>Dr Nancy Grasmick: And you know.
>>Dr Nancy Grasmick: It's fine to know the anatomy of the
brain, but the implications of the anatomy and how it affects
learning and how it affects teaching and how, in the most
important way, it affects success is what we're really
interested in.
So Doctor Denckla has seen thousands of children.
I have referred many children to her over my career, and it's not
only helping the child, but it's also helping the parents in a
very significant way.