Ann: Dr. Mark Burton's expertise and neurodevelopmental behavioral pediatrics is well established.

He's not only on staff at the New York Medical College, but also at the Wynward Teacher Training Institute where he helps educate teachers about child development, executive function, ADHD, and mind.

Dr. Burton has authored several books and has been actively involved in providing direction, education, training, and support to numerous national and regional programs and organizations, as well as parents and other professionals, and I'm pretty sure it's rare to find a physician with his credentials who's on the board of directors for the American Professional Society for ADHD and Related Disorders, who's also trained in mindfulness, leads mindfulness classes, and incorporates it into his private practice.

A few years back, Dr. Burton wrote, the older children grow, the broader the impact of ADHD with aging. More overt behavioral symptoms of ADHD tend to improve, yet H ADHD related impairments often increase. Dr. Burton, it's great to have you here today. Can you explain what you meant by that.

A few years back, Dr. Burton wrote, the older children grow, the broader, the impact of ADHD with aging. More overt behavioral symptoms of ADHD tend to improve, yet ADHD related impairments often.

Dr. Burton, it's great to have you here today. Can you explain what you meant by that?

Mark: It's great to be here. And I think there's kind of two important things to understand about why ADHD changes as kids grow older. Uh, the first one actually, before talking about ADHD specifically, I think it's important to understand, uh, a developmental path called executive function, which relates to ADHD.

Many people think ADHD is a developmental delay of executive function. So the reason those two questions relate is that executive function, which are like our self-management skills, is a developmental path, although one,  , most people are not quite as familiar with, and it matures until we're almost 25.

So if you think of executive function, uh, it includes kind of the old cliched view of ADHD. So it includes, or it's not cliched as much as minimalist, I guess, attention and behavior, but executive function is almost anything. You can put the word management to safe, to manage attention. When you're younger, you have to manage your impulses.

Um, as you grow up. You have to manage projects, you have to manage time. You have to increasingly manage your emotions with more skill manage relat. All of that means all of those different skills have an aspect of executive function to them. So the reason ADHD itself becomes more challenging as you get older is as life gets more complicated, as the demands go up as you're expected to be planning and coordinating more and more.

Um, and executive function is maturing so that it's no longer when you're younger just about attention and behavior, but about all these complex life management tasks. Um, if you see it that way, you can see how ADHD. potentially affects almost any aspect of life. So as kids get older, a lot of the behavioral stuff, both because the brain is maturing and because of treatment, often settles out, but the issues around health routines and time management and communication become more intense.

Ann: Got it. So, Dr. Burton, since the executive functions are,  , I guess, are they delayed for kids with ADHD or is, is that the case?

Mark: Well, I think some of it is just a practicality in that you can't measure executive function quite like you can measure.

You know, like language based skills on the one hand. And on the other hand, the model of ADHD as a developmental delay is mostly true, except that it isn't so much that you're, you know, that implies everyone's gonna outgrow it. And that's not entirely true either. But the easiest way to understand it, I think as a parent or teacher is that it's really a developmental delay in self-management skills.

There are a couple of ways people thumbnail that, but it's. Uh, estimated sometimes is like a one third delay in certain skills. Sometimes another way of looking at it as a several year delay in certain skills, and it's not so much that the specific measurement matters as much as the concept that you can have a completely brilliant 15-year-old who is, you know, maybe academically ahead of the curve in some specific skills, but more like an 11 year old or a 12 year old in terms of managing school.

And it comes across as they. They get mislabeled as lazy or unmotivated or start to feel bad about themselves cuz they don't understand what's going on. And it isn't that, it's that since ADHD and executive function are related to your ability to persist and plan and remember, it just undermines so many other parts of life.

So it's more,  , I think at some level it really is a developmental delay in skills, but it's. . I think on a, like a lot of things around ADHD, the way more important thing is just, it's an important concept and it's, it's an important way of living with ADHD, especially as a parent or teacher, to understand that it is an actual skillset and kids with ADHD are actually behind in it.

So I think a concrete example is if a child's forgetting to hand in their. You know, that's not a motivational issue. And it's not just that, you know, they need to care more, they need to try harder. You have to remember that forgetfulness is an ADHD symptom, and therefore any solution we gotta offer them has to be more skill-based, more needs to be, how are we gonna create a system for them with them that helps them remember better? Right?

Ann: Right. I can remember with my son who has ADHD in like fourth grade, I believe it was, we would practice at home. I even drew the classroom and said, okay, when you walk in the door, what are you gonna do? Because they had to put their homework in a bin and the teacher was not. I guess amenable to asking him for his homework.

It had to be put in the bin. So we worked over and over on. What do you do? As soon as you walk in the room, you go do your lunch thing, whatever it was, you go put this up, you go put your homework. But what, what would you say to teachers who are. Very reluctant to want to do, you know, any kind of accommodation or, you know, tap a kid on the shoulder and ask for their homework or, you know, we've had, I've heard over and over again, you know, eventually he's gonna have to learn, so you might as well let him sink or swim right now. So what would you say to those teachers or parents that say that?

Mark: Um, well there's a lot to that question, I think. And part of it I think is just that people don't see, you know, executive function based skills are something that many of us are raised to feel are just more a matter of, you know, effort.

You know, you just gotta try harder. So I think some of it is just lack of understanding. So it starts from just understanding that, you know, you wouldn't blame a child for having language delays or just sort of assume that they're gonna pull up their, you know, pull themselves up by the bootstraps and, you know, develop language when they have language delays.

You, you're gonna be. Probably upset by it, but also practical about it. Get them speech language therapy, you know? And if a child has a more overt physical injury, you know, they can't get to class on time because they hurt themselves playing football. So they're just moving slow through the hallways. You know, we accommodate to that until we, until they're more mobile again.

So some of it is just the lack of understanding. I think there isn't a lot of,  , you know, universal training around ADHD, even in medicine, much less. , you know, in teaching, you know, like, I mean, just to lay, you know, to put it out there, like I come from a family of special educators, like I'm immersed in this all the time, and it's just not standard part of teacher education, right?

So part of it is helping them understand that side of it. And then the second part of it, which is,  , you know, harder to sometimes to Intuit is that when someone has a deficit in executive function skills, when someone's struggling with. , you know, they, from their end, you know, they're really probably doing the best they can.

By nature, I mean, people generally do the best they can by nature, so that, you know, not handing things in is not a lack of caring an effort. You know? Or not. Or, or you can even look at something like impulsive behavior. I mean, that's not a choice, you know? It's not that they don't know better. In fact, one of the best one line descriptions of ADHD ever by Russell Barkley is that it's not a disorder of not knowing what to do.

It's a disorder of not doing what you. . So when you step back and see it as a bunch of skills, you know, that sort of sink or swim approach, you know, just doesn't really work most of the time because if someone doesn't have a skill and you just keep insisting that they developed that skill, really what it often does is cause a lot of, you know, frustration and angst.

You know, it doesn't, it's not like they're suddenly gonna know how to follow routines better. Uh, a much better model for it is a more developmental model of if you want a student to succeed. You know, kids are very experiential learners. We make sure we meet them where they are developmentally, make sure they're having a positive experience, not in a false way, but by creating the right structure so they can succeed.

And then more gradually, you know, withdraw the supports as they develop skills and as they show themselves capable. And that's how children, you know, continue to thrive and develop confidence. So if you have a fourth grader that you're saying when your son was that young who just can't follow a, a routine, if you go back to what I said, About that developmental delay model.

You know, on some level you can look at it as they were, you know, he's probably roughly nine years old, which means from the ADHD model, his ability to follow the classroom routine might be more like a six year old. And just, you know, just pushing without providing supports doesn't teach much. That's really the answer.

So for any skill, right, you know, one of the ways I sometimes talk about problem solving with ADHD is you can look at any challenge that's coming up and. if you have a good sense of what executive function is. You know, one thing I would add is that part of living with ADHD is you probably want to educate yourself to the point where executive function feels like a real thing and not just like a scientific term, right?

You know, that is the practicality of what you're living with when someone's living with ADHD is some pattern of poor executive function. Um, once you've identified someone who has ADHD, then you can kind of look at any challenge that's going on. sort of problem solve through the lens of executive function and it's, it's like a what if exercise.

It's not that life is always so simple, but it can be really valuable to say like, what if that issue going on was all executive function? You know, what will we do to manage it then if it had nothing, you know, obviously it's intentionally overly simplistic, but, but it is a useful way of reframing things.

You know, what if he's not writing his homework down in his notebook entirely because of executive? , because that's one of my favorite games to play, was writing with, with the, specifically with writing things down in your to-do list. Because it's like, you know, it seems like, well, if you cared enough, you'd write it down in your to-do list.

Right? Just write it down, except that you know, that requires, you know, planning and organization and focus and controlling your impulse to get on the playground and being organized enough to know where your pencil is. And once you get the book out, you also have to be somewhere else in three minutes. So knowing how to get to the right page and, and all of that is executive function.

So that simple task, you know, is actually complicated. For someone with ADHD quite often it means that as a student, if you're gonna keep them successful and learning to their capabilities, it is, uh, more effort for the adults. It means teachers need to make sure the student is writing their homework down, otherwise their ADHD is gonna undermine everything, you know, in the short.

And in the long run, we have to teach them how to do it themselves. And that is one of the ways I often summarize supports for kids with ADHD in the short term. It's like a wide-ranging safety net. We don't want their ADHD to undermine them. And then in the more long term, we have to start identifying where they have to develop their own skills and where they have to sort of learn different techniques to overcome their.

Ann: Right. So, so while maybe accommodating them, you're, you're trying at the same time to teach them, teach the skills that they need so that you can kind of pull back on the accommodations.

Mark: A hundred percent. Yeah. People are often worried they're gonna be a crutch, but the reality is, is you know, that the, that the you know that the interventions are gonna become something students rely on. The, the reality is that you, you just about never see that. I mean, kids want it to be independent and if the adults are looking to get out of the way, uh, I picture it sometimes, like when you're teaching a child to ride their bike, it's like you're holding, and this goes all the way up through teenage years.

You know, you're, you're sort of holding your hand on the back of the bike until the last possible second. And you know, if you start to take it off and the bike wobbles, you put it on again for a second, you know, but your goal is certainly to let go. And that's sort of, You know, the model with a d h ADHD a lot of the time.

Ann: Well, that, that,  , I do wish that they would teach a little bit more of that in, uh, teacher training in all, all teacher colleges so that,  , teachers would understand that because that, that's a real struggle for parents of kids with ADHD for sure. Um, and, and you've touched on something else that I, I wanna ask you about the motivation piece because mm-hmm. ,  , you know, most parents of kids with ADHD, they, it, it is frustrating. We do know that it, it's a, it's a skill that the,  , you know, the executive functions are all,  , you know, the issue, but sometimes it does feel like they're just completely unmotivated. And, and I remember thinking that for a long time that he just doesn't wanna do it. He just can't do it. But what, what, what is deeper,  , what's at the deeper level of this motivation thing? I mean, you know, I know that one thing we struggled with, or I felt like my son was struggling with, was feeling like he was just completely inept. That once he was labeled ADHD and once he saw that he could not keep up with certain things, he wasn't fast enough to keep up with certain things that he just started, you know shrugging his shoulders and going, oh, well I, I can't do this. So I, you know, I'm not gonna try. Um, but what, what's going on with the motivation? And I think this goes for maybe a lot of teens anyway, with, with or without ADHD.

Mark: Well, OB obviously that's a huge, we could probably spend the whole hour talking just about that.

I know in the day. But in the biggest framework, I'd say, I mean, there's two things. I think you can break that into both, or, which are equally important. Y from the basic understanding of ADHD. And one of the hardest things I think, when I work with high schools to get everyone on the same page about sometimes is that executive function skills are your planning and goal setting skills.

So ADHD actually uniquely gets in its own way, even if you want to overcome your ADHD. ADHD is a planning disorder, so the plans you're making are gonna be undermined by your ADHD, which just, it doesn't mean you can't get past it. It just makes it all really difficult a lot of the time. So on one level, it looks like motivation is more complicated because you know, from the outside, whatever you feel like viscerally, like, I want to succeed in this way.

Um, that involves taking that motivation and connecting it to an actual plan, which involves persistence and time management and problem solving, all of which are executive function-based tasks. So part of what's going on that looks like bad motivation is really. , if you're distracted, can't keep track of time and can't keep, can't organize yourself.

You know, that certainly blatantly looks like I'm unmotivated even when you're not. It's just that you're struggling with a planning disorder. So some of it is purely the executive function issues, you know, at face value. I mean, not face value in a small way, but like I said before, it's almost like that model of what if this was all executive function?

So some of it can be. Largely attributed to needing to actually, you know, manage ADHD with more intensity and there's a lot of different possibilities. Then the other side of it, which I think is equally important to look at, is that kids with ADHD are often having a hard time in different ways. You know, if you look at that, one line of ADHD is a just not a disorder of not knowing what to.

But a disorder of not doing what you know, you know, that has some pretty amazing and deep implications for what it feels like growing up with ADHD because you're getting in trouble and you're forgetting things and you're off task, and you're not necessarily showing the world what you're capable of.

And that eventually can begin to undermine your mindset, undermine how you feel about yourself in ways that then do undermine your motivation. And in fact, that comes back to the question you asked earlier about why is it so important that parents and teachers. You know, create the supports that let kids succeed.

And part of it is because you have to show them kids are experiential learners. You can't pretend they're succeeding when they're not. You have to sort of, I mean, it's not easy, but you have to create a situation where, in a valid way, you know, empty praise isn't useful either, you know, but you have to create a situation where, because there's enough structure, they do learn that their effort matters and they can be successful and they gain confidence in themselves, you know, in the classroom and outside the classroom. And that's where, you know, deeper motivation comes from too. So without intervening for ADHD and creating that support network, kids really do, you know,  , you know, struggle in those ways.

I remember one study which talked about. , I don't remember the exact number, but you know, ballpark it was that by the end of preschool, kids are being corrected more than their praised at almost a three to one ratio. So, wow. You know, that has huge implications. And like you were saying a minute ago, then you do begin to doubt yourself. Right?

Ann: Right.

Mark: But you can't. And, and, and the nuance there, I think that's important throughout childhood is that, you know, kids don't learn exactly like adults do, and they're learning a little bit. Or a lot more sometimes from their immediate experience, you know? So it's just like things are happening and either, you know, giving them positive feedback or not.

I mean, that has behavioral implications for sure, but that also has to do with, you know, if you want them to feel successful in the classroom, you know, they have to have an ADHD plan that creates enough support that they actually are successful in the classroom. Right? Not in a false way, but in a literal.

Ann: Well, and I think, I think, uh, this is just my opinion, but I think a lot of teachers do get so frustrated dealing with the kids that are ADHD, that it's really hard for them not to show that to the kids. And I'm speaking from personal experience because I also have ADHD and I grew up with every single report card saying if she would just try, she would do so much better.

And, you know, you, you feel. Um, you feel that feedback,  , you know, it's internal. It, it's not just the teachers saying things to you, but you can, you can feel it. So it's very frustrating for a parent to sit by and see that happening. And it's also very frustrating as someone with ADHD to know exactly.

What your kid is going through. And, you know, for people not to appreciate that,  , and give them a chance or praise them for what they do. Right. But, and let's talk about that a little bit because from the parent's point of view with a, when you have a child with ADHD, and it's very similar for just a parent with an adolescent period,  , you know, it is, there's so much to deal with and, and you know, I read a million books on ADHD and learning disabilities and, and all the stuff, and it was constantly school, school, school and, you know, how do we organize this? How do we get the homework done? How do we do this? Mm-hmm, and there's always something to deal with. And, and with parents, just, just with a, with a, an adolescent, it is the same thing.

There's always something and we find ourselves, or some of us do, especially those with anxiety and ADHD. We find ourselves being very reactive and. , you know, I did not discover mindfulness until my son was 18 years old, so, mm-hmm. as a mindfulness practitioner and as someone who uses this in, in his practice, can you explain a little bit, I know this is mindfulness, we could speak for three or four hours at least, but can you explain a little bit about mindfulness?

Because once I learned what mindfulness even. It made a difference in the way I approached everything. I, I almost instantly became more mindful even before practicing meditation and that kind of thing. So can you take a level 1 0 1 approach to this and, and tell us about it?

Mark: Well, I think I, you know, I always appreciate the opportunity.

Mindfulness has become kind of like a buzzword and I think for it to actually be useful, you have to kind of throw out some of the cliches. Um, but the practice of mindfulness. As a starting point is one where we work on not some sort of perfectionistic view of being calm all the time, which isn't real, or having a quiet mind even.

Um, it's really just a reflection that we live our lot of life in a sort of distracted autopilot. You know, we're sort of like reactive and not exactly paying attention to what's really going on and caught up in our thoughts. And, and a lot of that's gonna continue regardless. But what we can learn to do is manage it differently. And the practice of mindfulness is one. Of trying to develop traits that help us be more resilient and,  , aware really. Um, one of the things I like saying, cause I, you know, obviously I don't script this and as I'm speaking I always wanna say, you know, you kind of wanna look behind the language of mindfulness anyway cuz it's kind of an experience, you know, so what we're trying to do, practice traits, you know, build traits through reinforcement that help us pay attention to what's actually going on with more consistency and less reactivity. You know, that's one way of saying it. So the mindfulness is often described as moment to moment non-judgmental awareness, which is kind of,  , an academic description.

But what it means is, You know, there's value when positive things are going on to actually take the effort to give them our full attention. Because quite often in life we don't, you know, which means we could have a moment we're enjoying that would help us feel stronger that day, but we spend the whole time ruminating over some problem and really miss out.

Or when it comes to what you're talking about with kids, you know, you can look at the fact. . You know, trying to get out the door in the morning is complete chaos. You know, and there's all these things going on, and you've been told by some, you know, psychologist or a doctor that you should try to praise the positives, except that in the middle of the chaos, you know, you're all caught up in it and you just don't even notice them until as you're leaving the house.

You know, it's like where the hell's your backpack? And that's the first thing your child hears. Right.

Ann: Mm-hmm

Mark: But so it's almost like that's mindfulness or the, or working with that is mindfulness is being able to, in the middle of the chaos, pay enough attention to realize, oh wait, he, you know, he brushed his teeth and he did his hair reasonably well, and he, you know, and you, and to just give positive feedback in the moment, or, or even enjoy it and appreciate it in the moment has a lot of value.

And then the other way to look at mindfulness is much more than this, but as a starting point, is recognizing that when the challenging things in life go on, if we're not paying attention to, we're often complicating them in countless ways. You know, we're acting mindlessly out of habit, or we're being reactive and yelling and escalating a situation, or we're compounding a challenging moment with homework by, you know, tying it to a story that goes 20 years into the future and all of that is, you know, is stuff we can work on too. So that it's meant to be very practical and really it is something that is accessible to anybody because we're not expecting perfection. You know, your mind stays busy and you know, some, everyone's gonna get reactive sometimes, and all of that's true. Um, but it's kind of like a gym program where each time we sit down and meditate or practice mindfulness or set the intention to, you know, pay attention to things, we're just building that ability a little in ways that if we don't put the effort in wouldn't happen. You know, we just live our lives in that rut we've been in basically.

Ann: Right. Uh, you know, I was,  , when I first started studying all this stuff and I was working on the emotional intelligence piece and learning about emotional awareness and, and emotional regulation, which I had, I had neither and, and then I found out about mindfulness and realized that, well, really it's mindfulness. That is the piece that is missing because once you figure out what that is and you can do, then you are more emotionally aware. Then you can, and once you're emotionally, once you're aware of those emotions, then you have a better chance, much better chance at regulating those emotions.

Mark: Unless it's your only chance.

Ann: Yeah. Yeah. And it's just, once you figure that out, I. Um, I said this in another interview. You, you don't forget that it, it's, you can't unsee it. You can't unlearn it really. Um, it, it's just helped me tremendously. So tell us a little bit about how, uh, a mindfulness meditation works maybe and how that helps us develop this mindfulness in the moment where we are not as reactive and where we can stop and have that moment of, of clarity.

Mark: Um, well, I would, you know, I'd just start by framing it that the, you know, the entire reason I started, I sort of had been keeping my mindfulness practice to myself for a while. I was practicing a long time and then decided to start offering it in, in clinical care is I realized,  , just how value it could be for parents because it's a way of developing our resilience and helping manage stress. And, you know, in stressful situations, we're not at our best and it just creates. You know, cycle that's valuable to try breaking and when it comes.

So when it comes to practicing mindfulness, that's a useful reframe because if people think they're gonna meditate and quiet their mind, they're often likely to quit very quickly or not even get started because they say like, oh, I can't, I don't think that way.

So really what's happening when we practice mindfulness is we're giving ourselves a couple of different things. I think a useful reframe is we're giving ourselves permission to. Do the practice without reacting to everything for a few minutes. And that's no small thing. So, you know, you talk about emotions and you're sort of, uh, giving yourself permission to say like, okay, you know, for the next 10 minutes or for the next 20 minutes, you know, whatever comes up, I'm gonna do my best to just notice it without reacting.

It doesn't mean in some other part of the day it wouldn't, you wouldn't wanna problem solve, you might, but what we're doing with mindfulness meditation is we tend to,  , we're trying to develop. capacity to be more aware by focusing on something that's really concrete and not emotional and sort of, that's, that is the premise of focusing on the breath.

So the, so the premise initially for all of that, the baseline of how we're getting started is simply that every time you breathe, there is a physical movement of your breath, you know, it's just, just happens. You don't have to control it. You don't have to do anything with it.

It is just something you can bring your attention to that isn't all of that chaos in your mind and the practice of it then is just doing your best to.

There's actually, there's a second part which is important to get to in a moment, but this beginning part is just noticing like, okay, there's a little bit of physical movement you know, you can do it even as you're listening here. You know, you can just do it for a couple of breaths, you know, breathing in, you feel your body move, breathing out. You feel your body move, and you're not trying to force yourself to do anything with that. It's just there and it's like a place you can come back to.

Um, you know, and, and really that is the practice in a non-spiritual way initially. It's just like that is playing and using awareness. Now that has lots of implications because what we're trying to do for those, you know, minute, those 10, 20 minutes we're sitting is to develop the capacity to notice when we're experiencing emotion or noticing when we're experiencing a thought without getting totally swept up in it.

So, you know, you start getting pulled away into that thought or pulled away into that motion and you just, and the moment, the second thing I said that's important is the moment you noticed you've gotten distracted again is the most important moment. The distractions are gonna keep happening regardless, and what's really important in that moment is you're also, it's almost a practice of self-compassion a little, because you're, you know, you're, you've gotten away from your intentions, which happens all the time in life, and you just don't, it's okay.

You just noticed the most important things, like, okay, there I was, I was distracted a little bit, and then you come back again to a breath. And if you just focus on a few breaths over, you know, a long sitting, that happens sometimes. And that's okay. And the reason that starts to spill over into everyday life is because you're reinforcing, you know, a different way of approaching things, a different way of relating to what's going on that becomes more familiar.

And, you know, there, there are many implications to it. Um, you know, one of them that I alluded to before is you can almost see it as a practice of. You know, because you might think, you know, most days when you're angry, you have a way of acting, in particular when you're angry. You know, most days when you're sad, you know, you have a pattern. And some of it may be perfectly healthy, but for most of us, there's some not so useful habits too.

And what, and like you said about emotion, you know, to develop an ability to manage your emotions, you know, there's multiple layers to it. One is, is you need to be aware of your emotions. A lot of us are raised, people are raised in different ways. To either ignore emotions or some emotions are okay and some aren't. And in the end they're always gonna be there. You know, we have to, they, they, they're a signal for something, you know, we have to develop awareness of our emotions to learn from them and learn to manage them. So part of what's happening when you let your mind settle is you become more familiar with, oh, that's what's really, you know, that's what I'm really feeling right now.

You know, when in the chaos of day-to-day life, we might not otherwise do that. And then you're also, which is really different than everyday life, certain.  You know, our modern world right now is pretty much, you know, pretty reactive and all over the place. You know, it's a very unique thing to spend, you know, that stretch of time, giving yourself permission, like I said, to experience whatever it is.

And in that moment, choose to just, you know, let it happen. Um, whether it's a positive emotion or a negative emotion. So you're literally directly developing your ability to manage emotions every time you sit. And then obviously that's gonna spill over into every day and you're developing your ability to notice when you're distracted and come back, which has direct implications with kids.

How often do you hear from your kids, like, you know, mom, dad, you're not paying, you know, you're not paying attention to me. You know, you're not. Right. You know, kids really value our presence and attention. So as you're practicing the ability to pay attention, not perfectly, but more often, you know, that begins to spill over in everything.

And it also happens to have a lot to do with managing stress, which, you know, I, I hesitate to say only because, you know, that's another mindfulness cliche. I hate all the mindfulness cliches. I mean, it isn't specifically a stress reduction technique, but it certainly is a stress reduction technique. It's just not only that but as if you look at stress, you know, you're trying to manage life as well as you can. You know, none of us manage things at our best when we're swept away by stress, I mean, stress is part of life, but when it takes over, that's obviously,  , intuitive that that isn't when we're at our best. But the challenge through life is that stress tends to perpetuate stress, so that when we're having stressful thoughts, that changes our emotional state and changes an emotional state change how we think, which changes how our body feels, and when our body's tense, that changes our emotional state again, and it just can just spiral and just become a way of life almost.

So every time we develop that same ability to come back to something as simple as like, I'm just gonna focus on breathing for a few minutes, or I'm gonna focus on my feet on the floor. Or it can be, you know, eating, I'm just gonna focus on this, you know, this, you know, donut for a few minutes just because it's pleasurable and it's gonna be something I can focus on.

You're also breaking that stress cycle and letting yourself, it's almost like letting the snow globe settle a little bit so you can handle the next thing that happens with a little more clarity. And all of that's going on just through every time you choose to, you know, meditate for a few minutes.

Ann: Well, you know, and I would add that for me, having anxiety and ADHD when I first started reading about mindfulness, I was like, what? Wait a minute, I, I don't get it. What are they saying? And I had to go to like 15 different sources to go, okay, wait, maybe I, now I get it. But I think that's the thing about mindfulness. It's very hard to explain unless you try it. Understand. Unless you take three minutes. And, and, and that's another thing, you know, when we're talking about, you know, doing a mindfulness meditation, let's say, it doesn't have to be an hour, it doesn't have to be 20 minutes or, or even five minutes. You could take one minute, which is about as long as I can ever manage, but just that. People who are listening would just try, you know, a, a meditation for one minute or five minutes or whatever it takes. I think you would, you, you're much better able to see what it is and what it does, rather than reading about it.

Mark: A hundred percent. I mean, it's a lot like trying to explain like a gym program. I mean, at some point you just gotta go to the gym. You just wanna get started. Like, don't worry about all the rest of it. Just try it. Right. It's like, it's like if you wanted to run a marathon and you've never gotten off the couch, , you know, just start, walk, just start walking, you know?

And we're gonna build up from there. Part of the power of, I think mindfulness is this ability to approach challenges. You know, and approaching challenges with less reactivity is just problem solving and navigating them more easily. You know, it's difficult to make tough decisions when you're caught up in all that, because I do think it isn't fair to talk about ADHD without putting in the context of like, part of the problem solving has to do with everything we've talked about today, like understanding it and working with executive function, and then part of it.

You know, the challenge of how complicated the actual intervention itself is and just, you know, I, you know, it is important to put mindfulness in the context of it's a valuable foundation for ADHD care, you know, and then as a support for navigating school-based plans and behavioral interventions and decisions about medications.

And all of that's true. Also, you know, it's, it's, you know, it's a very complicated, uh, to come back to ADHD. You know, it's a. intricately complicated condition, and that makes the interventions, you know, very wide ranging, quite often, and changing over time.

Ann: So, you know, I know parents, we had a long, hard, journey with the whole medication thing. Is there any advice you could give for parents on that ?

Mark: Yeah. Again, there's so much there, but I would say, I mean, I'll take it in steps. I mean, one of the biggest things I think that's really important when it comes to medications first is just starting from the premise that these are all brain-based disorders. And I think it's totally unfair to parents and families about, uh, dealing with all the judgment that's added to all these medications.

So, as a starting point, even before I get into the actual practical, you know, the, it, it actually ties back to mindfulness a little bit. You know, the practice of non-judgmental awareness means like looking past our biases and views to seeing what's actually going on. you know, so it's with the ADHD medications, the short of it is they are,  , highly safe and effective if they're used, right.

They've been around about a hundred years, you know, somewhere near 80 to 90% of people can use them without side effects if you manage them well. Um, so the most important starting point I think is separate from the actual decision making is just letting go of all the emotion and judgment around them as best as you're able because,  , it's a difficult enough decision without that, you know, so the way to look at the decision around medications to me is that it's really no different than any other decision in pediatrics.

No one should use a medication they don't need for anything, you know? ADHD medications are really no better or worse than anything else in pediatrics if they're used, right? So, you know, it's hard enough to decide to use a medication for your child, for anything. You don't need to add on all the misinformation around these medications.

So that's, that's the starting point that I think is really important.

And in the end, unfortunately, managing ADHD medications is all about the trial and error. It's all about persistence. That endpoint is highly successful. Most people can benefit if they choose to. You know, go down that path with a ton of trial and error. Although the nice things about the, uh, ADHD medications is actually most of them are kind of what you see is what you get for the ADHD medications. You don't need to watch and wait much. This is just, it is just a challenging path that requires a lot of,  , making the best decisions you can short term and being flexible to respond to what comes next, but you can't know for sure.

Ann: which is why mindfulness is so important for parents when they're trying and going through all this stuff.

Mark: A hundred percent. I mean, I often talk about, you know, the, the beginning premise of practicing mindfulness way back when was, you know, was, was something along the lines of like, life is inherently uncertain and changing and, you know, we're gonna be more resilient if we learn to,  , sort of live with that reality. That's one way of looking at it. You know, we, we can spend an awful lot of time trying to, you know, make things feel fixed and safe and permanent that are never really gonna be for very long. And,  , and parenting is like, you know, all of that a hundred fold, you know, it's like parenting is like exactly all about uncertainty and change constantly.

And that's exhausting. So, the practice of mindfulness,  , really can just help us feel more stable and resilient as parents and maybe a little happier as parents, which is only gonna benefit our families .

Ann: Right. Well, and, and one other thing about the medication, especially when we're talking about adolescents,  , I know a lot of parents are, are concerned, and I've heard people say this, well, I don't wanna put my child on medication, and I certainly don't want them taking, you know, speed when they're in high school because it's just gonna cause substance abuse. And I, I don't wanna go down that road. So how, how would you answer that?

Mark: Um, well, there, I mean, there's two bullet points that I think you need to know. I mean, one is, ,  , when you're, you know, ADHD is clinical medicine, so you know, you gotta start from the point of if you're comfortable with the diagnosis because there's no test, right? Assuming you're comfortable with the diagnosis, then ADHD is a medical disorder. So using the ADHD medications is trying to normalize functioning of parts of the brain related to attention and executive function. So you're treating something just like you would treat high blood pressure or asthma. Um, and in the field of ADHD, the research shows if you treat ADHD appropriately, your risk of substance abuse goes down. So untreated ADHD has a two to threefold increased risk of substance abuse,  , while treated ADHD does not. That's really what it comes down to.

Ann: I wonder is, is that because of the self-medication that, that people who are not taking medication?

Mark: I don't think anyone can prove it one way or the other, but  , part of it has to do probably with people self-medicating in a way and part of it, but part of it is, ,  , you know, ADHD is a self-regulatory disorder, so, you know, all basically un undertreated, ADHD is more and more linked to a variety of poor health outcomes. Um, and so that's, you know, and it has to do with how you're living life day to day, which is another part of what's probably relating to the substance abuse issue. But that's not, you know, that's more theory than, you know, something you can.

Ann: So, bottom line treating ADHD if it's, if it is truly you, trust the diagnosis, it is ADHD, treating it with medication is not going to put your child at risk for being a substance abuser. It would be more likely that would happen if you did not treat the ADHD with medication.

Mark: That's what I mean. I would say two things. I mean, treating, ADHD is not about medication alone. It's one of several decisions, but yes, the ADHD medication use has been shown ADHD medication use in people with ADHD. The more recent studies have shown decreases the risk of substance abuse. You know, and, you know, full ADHD interventions have to, would really look at, you know, that plus, you know, potentially at educational supports, you know, behavioral supports, working with a coach, all of it. It's a lot to take on. since ADHD affects so many parts of life, the more,  , coordinated, the more,  , comprehensive your ADHD intervention is, the more likely you're gonna get past a lot of the things ADHD can cause.

Ann: I read your book, by the way. Loved it. Love your book. Uh, well love the, the,  , the parenting, the mindfulness for parents. Where is it? You mentioned several mindset shifts. I think that's what you would consider it that parents need to make when it comes to behavioral changes. And I think this applies for all teens, not just ADHD teens. Um, you said really that you need to think that they can not, rather than they will not. I love that. Mm-hmm. that to look at everything through the lens of executive function, we've talked about that. Observe with curiosity, not judgment, and to let go and, and this is big. I think this was huge for me. Let go of prior assumptions or expectations of what your child can do. And again, I think this is good for, for all teenagers, not just those with ADHD, but,  , can you kind of maybe expand on any of those a little bit?

Mark: There's two things that come to mind for me. From the side of executive function, I really do see some pretty profound shifts happening. Just when. Begin to understand what executive function is and how it comes across in day-to-day life. So, you know, one uh, example that's come up for me that I, I've talked about a lot this year is I was seeing a family this year, earlier this year who had a young child who had a lot of emotional reactivity, and I had just met them and we just talked through, I mean, we did evaluation, which happens over several visits. I talked to them about ADHD and executive function, and they came back for their first visit where we were gonna get started with the actual intervention, which by the way, in younger kids, is often largely behavioral. I, I feel like we were really emphasizing medication before. I mean, it's often a behavioral intervention to start.

Mark: And,  , when his mom sat down, she said things were already better at home and she was clearly laughing, so I knew we could joke about it a little bit. So I said, what do you mean things are better at home? I haven't done anything yet. And she said, no, now that I understand that when he gets all emotional, it's just part of his ADHD and he's not meaning it, you know, it's just like, it's easier to deal with, you know, it's not solved, but it's easier to deal with.

Ann: Exactly.

Mark: And so that shift in perspective makes a big difference in lots of situations. You know, that feeling as a parent that you get so frustrated, like, just stand in your homework. And it's like you gotta, you know, that it's just, it doesn't fix the problem, but it changes a lot when you can see it. Okay. Forgetfulness is an ADHD symptom. That's the same way often framing for teachers. It's like, you know, we can't effort our way out of being forgetful. You know, it's really frustrating, but we gotta, you know, work on it. And that is what I meant and what you're asking about, you know, I don't mean letting go of expectations for our kids.

We want to, we want to have high expectations for our kids, but in the short term, we have to look at, you know, just like we would in any other skill set, what do they need to work on?

Um, the other thing I think it's important to acknowledge as you say something like that though, which comes back around to mindfulness for parents is, is, is, you know, as we're doing that, it doesn't mean we can't also acknowledge how difficult it is for us as parents. I mean, it's, you know, both are true at the same time. It takes a lot more, you know, it, it isn't what we pictured and it's a lot more work. And that has to be acknowledged too.

Ann: Exactly. Um, I just think it, it's so helpful to remember, you know, they're not doing this on purpose, that they, if they could do better, I think it's Dr. Green that says, you know, if they could do better, they would do better or  , you know, this is not something they'll, they are willfully doing just to displease us, you know, it, it's, it's a big shift in our mindset and, and that was so helpful, to me when I first realized that, that, you know, all of these challenges, all of these, you know, behavior issues can be seen through the lens of executive function.

And, you know, once you realize that this is not something they're doing on purpose, it does, it, it softens things a bit. I think it, it lands differently, you know, with us.

Mark: Yeah. I, yeah, I hope so. And, and it's particularly valuable to see it that way in teens for two reasons. I mean, one is, is that one of  , more modern understandings of brain development in general is that executive function skills actually improve until your mid-twenties to begin with, which I think is something anybody, any mom of a teenager it's, or dad of a teenager, it's useful to know because.

Ann: Yep.

Mark: You know, the reason teens still need parents is even the best of, even the best of the bunch in whatever, whatever best is a judgmental word, whatever word you wanna use.

Ann: Yeah.

Mark: But even, even the most advanced of the bunch is 10 years away. really having a mature brain. You know, executive function is all about long-term judgment and planning.

Mark: And the reason teens need parents involved, even if, you know, we, we, you know, they need lots more freedom as they're teenagers, but we do need to keep in mind as parents that they're 10 years away from having a mature brain without ADHD. And then if you have a child with ADHD, you know, it's, it's a real disconnect as a parent because on the one hand, developmentally,   part of their job is to become more independent and define themselves in all the things teenagers do.

  And on the other hand, being immature in executive function is a delay in independence.

Ann: Right.

Mark: And that doesn't necessarily, that is not an easy situation. You know, there's a no, it.

Ann: so well, giving ourselves a little bit of compassion and learning mindfulness certainly does help and, and the way you explain it certainly helps and I really appreciate scientists, physicians like you that help bring this practice to parents and you know, especially parents of neurodivergent kids.

Um, thank you so much for being here with us, Dr. Burton today. I really appreciate it and I know my listeners did as well.

Mark: Well, thank you so much. I appreciate the opportunity and nice meeting you.