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You’re listening to Insights at the Edge. Today, my guest is Dr. Mark Bertin. Mark is a pediatrician, author, professor, and mindfulness teacher specializing in neurodevelopmental behavioral pediatrics. He’s a regular contributor to Mindful.org, HuffPost, and Psychology Today. With Sounds True, Mark has written a new book called How Children Thrive: The Practical Science of Raising Independent, Resilient, and Happy Kids, where he teaches that by understanding healthy developmental stages, parents are better able to support their child’s well-being. Using new insights from the science of executive functioning, Mark Bertin shows that a supportive, fun, growth-promoting environment is what kids actually need to thrive.
In this episode of Insights at the Edge, Mark and I spoke about the development of executive function from preschool through early adulthood and a gut-level sense of how executive function develops in stages. We also talked about his research and writing on ADHD and how ADHD is a medical disorder and a developmental delay in executive function, and how his work with ADHD led to his new book How Children Thrive. We also talked about the classic Marshmallow Test, and how healthy play helps develop good self-management skills. Finally, we talked about how to set limits within a family on technology use, how mindfulness meditation promotes executive function, and the connection between self-management and the ability to manage others and even contribute ethically and meaningfully to the world. Here’s my conversation with Dr. Mark Bertin.
Mark, to begin and as a way to give our listeners a bit of an introduction to the work that you do—you’re a developmental pediatrician. What’s that? How is that different than just a pediatrician?
Mark Bertin: Well, developmental pediatrics is a subspecialty of pediatrics just like cardiology or pulmonology are. So I actually was a general pediatrician for several years and then I did a fellowship in all the nuances of child development.
TS: OK, that makes sense to me. So you’re a pediatrician who’s an expert in child development.
MB: Yes, practically speaking my days are lot more—from the outside, they’re a lot more like a psychologist probably, the way people traditionally talk about it. I don’t do anything much acutely medical anymore.
TS: OK, and in your new book, How Children Thrive, you focus on what you call the “developmental path” of executive function. You go so far—and this is a quote from the book—to state that “executive function is the bedrock of raising happy and resilient children.” So to begin with, can you introduce our listeners to what executive function is and why it’s so important?
MB: Yes, absolutely. I guess there’s two different things I would say about it. Practically speaking, the way to think of executive function is that it’s a cognitive skill set that has to do with managing and organizing our lives. It’s one that I don’t think has been talked about much or enough, meaning that—one of the examples I think I use in the book is that you can have very concrete information about something, like: How would you run a restaurant? Somebody at 10 or 11 might be able to list all the parts, but they’re not going to have the sort of organizational skills to stay focused long enough to manage time, and plot things out, and keep track of the big picture until they’re much older. So there’s a difference in child development between knowing stuff and being able to manage it and handle it day to day. The same concept goes for even academic learning where you can know a topic pretty well, but you often need to be able to focus, and organize, and plan, and do this other larger level of management in order to do well in school.
From a research point of view, there’s a lot of research developing that says that having really strong self-management skills in early childhood predicts a lot of very long-term measures of success. In essence, we can’t control everything for our kids, we can’t predict everything that’s going to come up. But these are a lot of the abilities that are going to let them, over time, learn how to handle their own lives independently.
TS: OK, so right here at the beginning for the parents, grandparents who are listening, what activities, what environments support executive function and the development of this cognitive skill set? And what impairs it or makes it harder?
MB: Well it’s a great question and I think while we’re talking there are actually two things that I think are really important to look at. One is that question of how do we promote it, and then the other is really recognizing that when we can understand executive function, it really impacts choices we can make around just day-to-day parenting. It impacts things like managing homework time, and technology, and bedtime. But in terms of promoting and building executive function, it changes as kids grow up. I think that’s one of the core concepts here that hasn’t really talked about that much yet that in general parenting is that this is something we can track, kind of like language abilities. You don’t expect a one year old to speak the same way as a five year old or a 15 year old, and executive function is the same.
So in very early childhood, I think one of the important things to recognize about this is a lot of the things that help kids become more independent actually simplify our lives a lot as parents. It strips away a lot of the extra stuff that makes it stressful. So in very early childhood, for example, one of the foundational activities for kids because it develops these self-management skills is just open-ended play. We feel pressured as parents to schedule more and more classes, and even in preschoolers [there’s] this developmentally off pressure to teach them academics really young and maybe get them involved in all these structured activities.
Each of those things might have a role in the course of an average week, but the bottom line is if you had to look at what in very, very early childhood helps build executive function, it’s things like a stable family environment, balanced by clear limit setting. So it’s not either/or, it’s a very positive environment. But having very clear limits helps kids develop self-management skills. Then really prioritizing time for open-ended, imaginative play with family, with friends, and not feeling pressured to push kids faster than that. In fact, there’s some evidence in the preschool set that when they’re in environments that emphasize open-ended play more than academics, they actually in the long run are going to do better academically. Because developmentally they’re not supposed to be learning reading, writing, and math before school starts, in essence. Not that it’s wrong if an individual child has those abilities—perfect. But you shouldn’t feel pressured that the average child needs to be doing that that young.
TS: I have a couple questions for you, Mark, just to get clear here. I’m still wrapping my mind around what executive function is. When you talked about it as a cognitive skill set, I started tuning into that, and I was thinking about long-term planning and managing lots of details, but now you’re emphasizing the capacity for self-management. How does self-management relate to executive function?
MB: I think we’re actually saying the same thing. By self-management—when I think of executive function, it’s anything that requires that overall supervision, in essence. The metaphor we use a lot is it’s like the conductor of the orchestra. The musicians can be as talented as you want, but somebody needs to conduct the orchestra. Or the CEO of a business. So in day-to-day life—this is really important to me—all of this, if you’re listening, whenever anyone talks about this it really should feel practical, because this is a way of understanding child development that really changes how we think of things. So we have to, for example, manage our attention. We need to focus even on things that are challenging, and shift our attention between different tasks all during the day, and all of these things that have to do specifically with staying on task. So one part of executive function is managing attention in that way. You can track over childhood that children are able to focus for a longer amount of time as they get older, and also recognize that some kids can have difficulties with focus, and then we have to look at that as a skill we need to work on.
But then the rest of management and where this becomes much more—for example, the heart of classroom learning is managing tasks, managing time, managing emotions. It’s really complex on the bigger sense. It involves lots of different skills in the bigger sense, but on a practical level it really has to do with that day-to-day managing whatever comes up in life. You can look at, for example, disciplining kids and realize that in very, very young kids, because they can’t manage or conceive of time particularly yet, and they don’t have a lot of impulse control, and they don’t have a lot of foresight, you can use this to recognize that in younger kids there isn’t a lot of learning. Their behavior is going to change almost entirely from immediate feedback, because developmentally if you talk to an average four or five year old from that point of view of, “Can’t you see you hurt her feelings?” From a point of view of cognitive development, the answer probably on a practical level is, “No, I really can’t see that, because I haven’t developed that way yet.”
So that discipline in young kids really has to be very concrete, and black and white, and a lot of very immediate feedback tempered by very clear, corrective feedback—positive feedback, I should say—tempered by very clear limit setting too. Because when you get caught up in overly talking to very young kids about their behavior, it may have a relational value of keeping them in the loop and forming a relationship. But from the point of view of behavioral learning, you’re not going to get much of anywhere. Then when you look at the development of these life management skills over time, then by the time you’re a teenager maybe you have developed some capacity to tie your actions, tie the things you’re doing now to what happened earlier in the day, or what’s going to be happening next weekend. And your ability to discuss things and collaborate has grown. So now discipline might have to evolve because you’ve grown up, in essence, in that way.
Then it’s also important to recognize that that maturity of executive function—one of the reasons I think this is such an interesting aspect of brain development to understand as a parent is that executive function actually matures until you’re almost 25 or 30 years old, and it’s a big bell curve. So everybody, I’m sure, knows a teenager who’s well ahead of the curve and seems to be able to manage everything in life. We all probably know of people who were forced into almost running a family as teenagers, and many people do quite well with it. But if you look at typical development, most teenagers are 10 years away from having a fully mature brain manager. When you look at how they deal with really challenging situations in school, or smartphones, and sexting, and all these different things, some of it needs to be a recognition of you can be completely brilliant as a teenager, completely motivated as a teenager and still not really have mature executive function skills. You still need a parent’s involvement because your foresight is 10 years away from being fully grown up.
TS: Is there a certain part of the brain, Mark, that tracks along as we develop more and more executive functioning skills?
MB: Yes, there is, although you can’t really measure it in any concrete way. But yes, the part of the brain we’re talking about is the front part of the brain—it’s often called the frontal lobes, primarily. That part of the brain largely has to do with executive function. This was where some of the overlap with research in mindfulness comes, because certainly of the many activities that helps develop these self-regulatory skills, these self-management skills, the practice of mindfulness is one of them, and some of the research overlaps there. One of the ways we know that there’s this ongoing maturation of the brain is because we can see that, specifically in the frontal lobes. That part of the brain keeps maturing well into our twenties.
TS: Now I know you’ve written two previous books before How Children Thrive about ADHD. One was Mindful Parenting for ADHD and The Family ADHD Solution. What did your work with ADHD teach you about executive function that then led to this new book, How Children Thrive?
MB: That’s a really great question, because one leads to the other and what I think—well, let me start at the beginning of your question. The most practical way to think about ADHD—and there are subtleties to this that make it perhaps not literally true—but the most practical way to look at what it means to even evaluate if somebody even has ADHD is that it’s a developmental delay in executive function. So that it’s not really an attention disorder, specifically. Kids with ADHD have difficulty with attention and behavior, but really in the big picture what often gets in the way as they get older is they might have difficulties in organization, and planning, and time management, and keeping track of stuff in their head, and emotion, and sustained effort, all of which are part of executive function. So on a very practical level, ADHD is an example of what it means to grow up with challenges around executive function.
So for parents whose kids do have ADHD, I’d say two things, if anyone happens to be listening to this. One the one hand, I think too much gets made initially of tying the evaluation for ADHD to the treatments for ADHD. Because a lot can change, a lot can benefit children if you just see that it’s a skill set that’s behind, that they’re struggling just like somebody else might be struggling with a language delay or a motor delay. Then the flip side is all of ADHD intervention relies—to me, if you want to do it really comprehensively—on recognizing all the subtle ways being behind in executive function impacts life. So ADHD, for example, has been linked not just to school problems, but to overeating and car accidents—if it’s not treated.
However, after working all these years with my clinical work, my day-to-day work is a lot with kids who are struggling in different areas of development, so I do a lot of work with ADHD. Because of that, I’m pretty immersed in all of this—the whole world, the whole body of research and the practical side of understanding executive function. That ties to stuff like the Marshmallow Test, which you might be familiar with—which we can come back to in a second, but it’s a very early measure of self-management skills that appears to be a predictor of decades of success in different ways as children grow up.
So what I’ve been able to do, become more and more interested in, is just recognizing that we can take that same understanding of executive function and then make it practical for general parents. Because when you look at what children . . . when you begin to get a more gut-level feel of what executive function should be at different ages as a parent—or typically is, should is a very loaded word—but typically as a parent, it really can help you see what will most set your child up for success at different ages.
So if you look at even something as often immensely frustrating but practical as sleep training, when you step back and recognize that the average young child doesn’t really have that much invested in sleep, and doesn’t necessarily like going to their room at the end of the night, and might get a little bored lying there, and in essence has no larger perspective—no brain manger yet to say, “In spite of the fact that this isn’t the most fun thing to do, I’m going to feel so much better tomorrow if I get a good night’s sleep.” That just isn’t possible really through elementary school for many kids, sometimes even later. You can see that even if they could read a book with you and practically understand that sleep is important for the human body, they just don’t have the larger skills to manage bedtime themselves.
When you look at it that way, you realize what the research happens to show, which is that usually speaking, healthy sleep in early childhood comes from parent-created routines because parents have the mature brain manager in the room. So that overly discussing sleep, fighting over sleep, doing things like sitting with your child as they fall asleep, all of these things often don’t teach your child to sleep well on their own. Many of us have—sometimes you get lucky and have a child who happens to be a very good sleeper. But whenever sleep issues come up you just have to remember that instead of getting—that all the answers are going to come from the stronger brain managers in the room, the adults in the room have to come up with the solution and not worry about the discussion side as much. You’re not going to convince a young child to sleep better, typically.
TS: OK, there’s a lot here and I want to unpack some of the things you’ve said. You said one of the important things as a parent is to get a gut-level sense of what healthy executive function in development might look like through the different ages.
MB: Yes, that wasn’t a very practical way to say it, was it? That’s a very wordy way to say it.
TS: Actually, I kind of liked it. What I liked was this gut-level sense, that there’s sort of an intuitive sense of, “Oh, my kid is starting to develop these capacities in an age-appropriate way.” So just take us through some basic age distinctions and what healthy executive function coming online looks like.
MB: Sure. Painting in broad strokes, certainly in preschool I think one of the more—some of the newer science is that there even is a path to executive function. So what you’re seeing in preschool—the way I think it’s easiest to see it is you compare different points in time: What changes between when someone’s a toddler and a kindergartner in terms of self-management skills? So you can look at across all of these different areas. If you expect a preschooler to focus too long, again, if you push academics really young, you have to recognize that when it comes to executive function, part of it is sustained attention and there isn’t any reason. In fact, there’s a little research saying that by kindergarten if kids are in overly academic setting they could be falsely diagnosed with ADHD, because our expectations are too high for what they’re capable of. They’re not going to be able to do it.
So [in] preschool, you expect an evolving but relatively short attention span, you expect an evolving sense of behavior that’s really just rudimentary impulse control. Sometime during preschool you have to start dealing with the frustrations of “someone took your toy” without reacting to it. But you don’t have any sense yet of, first of all, time. So when it comes to discipline, if you [use] the old cliché of: “Don’t do that, because when your father gets home . . .” By six hours later they might be upset that they got in trouble, but they can’t really tie the behavior together and they can’t really plan it all. I think that’s probably obvious in a preschooler, but that’s executive function too. So in preschool kids, what you expect is a lot of immediacy, some leftover impulse control, a fairly high activity level that’s supposed to mature and decrease until by kindergarten [or] first grade, they can do well in a classroom. And not much of an ability to plot and plan things over time.
Then as you get to school age, I could speak for hours about how executive function turns out to be really what sets kids up for success across all sorts of academic abilities. So on the one hand, executive function is your ability to increasingly just manage your schoolwork, to get your schoolbag back and forth from home to school. Then if you think about, again, the difference between early elementary school and middle school, at some point in there you develop a capacity to manage time, to handle a project. That’s all executive function developing across elementary school. Again, if you pressure a third grader to do that, which I do see sometimes, there are schools that seems to be putting increasing pressure on younger and younger kids. You wouldn’t expect someone who’s in third, fourth grade to know how to study or to know how to plan a project without an adult reaching out, and helping them, and giving some guidance. If they don’t get that guidance, it’s going to be very stressful and overwhelming for them, because they’re just not cognitively there yet in terms of that particular skill set.
But it also turns out executive function—there’s something called working memory that’s part of it. That’s how you organize information in your mind, like as you’re listening to a conversation like this, it’s the part of your brain that’s picking out the interesting details and maybe connecting them to other things you’ve learned in the past. Then in terms of our discussion, it’s where you’re formulating the next question. All of that is working memory. If your working memory is a challenge for you, you’re going to have a hard time with things like narrative writing, organization your thoughts to get them on paper. So there’s some people who think that expecting very young kids to be organized in their writing is developmentally off. Of course, many of the writing programs in schools nowadays push writing at an incredibly young age. Some students are going to do fine with it, but others who have a hard time with it aren’t necessarily developmentally behind, they just need more of that type of instruction.
So through school, I think the easiest way to think of executive function is it’s that increasing capacity to do more and more complicated academic activities. Not that that’s the only thing executive function is doing, but I think it’s the easiest way to picture it. It’s a perfect example of that gut level. Sometimes you need to step back and if you have a six or seventh grader who on the one hand is in a pretty demanding school, and on the other hand has open-ended access to a smartphone and computer time, and no one is guiding them on how to manage a project, not get sucked into YouTube when they’re meant to be doing their homework, demonstrate impulse control by not texting their friend in the middle of a—all of this is executive function-based decision-making. So you can step back sometimes and feel like, “Oh right, he’s only 10, he’s only 11.” Or whatever, all the way up through the whole developmental path and say, “Maybe what’s going on here is he needs me to step in and teach something to develop a better plan here, because the planning is too difficult.”
Certainly technology is its own complete—really part of why it’s so challenging for kids is because those of us with adult executive function and adult brains are trying to minimize its impact and use it well in life. If you have an immature brain—excuse me, developmentally appropriate but just not grown up yet—and then have this product that’s made to hook us, and keep us engaged, and really is a whole lot more interesting than your homework, of course it’s going to lead to disruption a lot of the time.
TS: One of the points you make, and I think it’s such an important one, is how the parent has to be the brain manager for the person whose executive function is still developing.
MB: Absolutely. That is a core point that I think when things get stressful and busy sometimes just gets lost. So to just finish the next step of the developmental path of childhood, you can take that concept that you just raised and bring it all the way to teenagers and recognize that teenagers need a lot more independence, a lot more collaboration—it’s a whole other ball of wax. Yet you have to recognize once in a while that you are the mature brain manager, and they are 10 years away from having a mature brain manager, so that you let them show as much independence as they’re capable of. But in terms of that gut-level decision making, the trusting yourself when it comes to child development, if you really begin to get a sense of this is what it means to be mature in all these different ways, there’s going to be times when you recognize “OK, but that’s not OK.” We’re going to step in here now and either set a limit on the one hand, or just recognize that maybe it’s just something that needs to be taught. Maybe it’s something that isn’t instinctual for my child yet. I have to work on this a little bit here. Which is harder in teens than younger kids, but it doesn’t mean it’s not doable, it just has to be very different in older kids.
TS: Now, let’s circle back around. You mentioned the Marshmallow Test and you begin your book, actually, talking about this research study. It’s obviously an important touchstone for the development of executive function.
MB: So one thing that’s important to recognize even before I mention the Marshmallow Test: there’s no one test that defines anything in childhood, but I think I use it a lot—a lot of people use it a lot—because it demonstrates this whole field in essence, the sort of beginning point of this whole field. So the Marshmallow Test is an old experiment at this point where the gist of it is: a child goes into a room with a researcher who almost immediately pretends to get a phone call and says, “Look, there’s a marshmallow on the table there, and I’ll tell you what—I’m going to be back in just a minute, I have to go get this call. But if you can just wait until I get back before eating the marshmallow, I’ll give you a second one. So you can have one now, or if you can wait a few minutes, I’ll give you two.” It turns out they used different treats and stuff too, it wasn’t always marshmallows. It was something a child really liked. Then that was the initial intervention almost in its entirety.
So then they watched from the outside what happened. They were able to group some of the kids into either being low delayers, kids who immediately went out and grabbed the marshmallow, or high delayers, which often it looks a little bit like out of Candid Camera where kids are smelling the marshmallow, and sitting on their hands, and singing songs to themselves, but they find a way to wait and get the second marshmallow. This is painting in broad strokes, by the way. These are looking at trends in child development, so if you have a child who loves marshmallows so much that they can’t wait, it doesn’t mean that they’re going to have a problem all the way through life. Then the flip side of it, which a friend of mine pointed out at some point, is that there must be some kids out there who are just so mature in their thinking they’re like, “I might as well have one because who needs two.” So there’s many nuances to the study.
But then when they follow these kids up what you find is that the low delayers, the kids who in general are exhibiting more difficulty with self-control have more behavioral issues in preschool. So this preschool measure of self-management skills, of impulse control, and other skills like that predicts some behavioral outcomes. But what really becomes interesting is Walter Mischel and the people who do this study were able to track those kids until they got older, and in high school the kids who—based on this one preschool measure of self-management skills—the kids who had stronger self-management skills were more likely to do well on standardized tests in high school. Then somehow they were able to track them through another decade, and as they got older, they kids who had stronger self-management skills were less likely to become overweight. All based on this one test that had been done in preschool.
There have been other groups studying similar patterns of development. One group, for example, showed that having stronger attention skills in preschool predicts graduating from college, another group looked at outcomes like income when you’re an adult. The bottom line is that strong self-management skills even in preschool set you up for really long-term success in a lot of different ways, which is why on the one hand we’ve been emphasizing—it cuts both ways, we’ve been talking some of why understanding executive function really just helps you make easier choices as a parent a lot of the time. It creates that foundation of, “This is what makes sense for this situation.” But the flip side is clearly if self-management skills are this important for all these different outcomes—academic outcomes, behavioral outcomes, social outcomes—we want to do what we can to promote them as parents also.
TS: When you talked about promoting self-management skills at a young age, you emphasized play—open-ended play. I’m not clear how open-ended play helps someone become a high delayer, if you will, versus a low delayer.
MB: Sure. Well, first of all, it’s all about the overall picture. But the reason—I’d say personally I find it very reassuring, you can almost say that play must have evolved for a reason. It has social implications, it has other implications. But the reason play begins to affect executive function, presumably, is because when you’re playing imaginatively you have to keep ideas in mind. There’s a cognitive aspect to that, just holding—like I mentioned a few minutes ago, working memory is the ability to hold information in mind and manipulate it and change it. There’s a degree of impulse control, because when you’re playing with a bunch of kids certainly it might just be—now we’re playing pirates and now we’re not, now we’re playing baseball. You need to in that moment reign yourself in and follow along at some level, and if you’re not going to follow along you need to, in a socially appropriate way, negotiate the situation.
So all of free play, because it’s all driven by your imagination and your cognitive capacity to flexibly change what you’re thinking, to navigate something on that larger level, those are all abilities related to executive function. Then there also are—you can almost look at any form of play that requires focused attention, and concentration, and figuring things out is probably going to build executive function too. There isn’t quite as much research around that. But there is a group, I know, studying chess in England to see if playing chess builds executive function and attention. A lot of forms of traditional play really do help in development in this way.
There are programs, even. One of the better studied programs around this is called Tools of the Mind, and that’s an early childhood program that relies on largely—basically taking things like a situation where you say: “Let’s pretend we’re in a store,” and then after a few minutes you say to the kids, “Let’s switch roles now. Now you’re going to be the shopkeeper and you’re going to be the person buying.” In all these things there’s an aspect of impulse control, an aspect of working memory, an aspect of cognitive flexibility to it all. So that’s one way to use it. The other way to use it is really just through traditional games, like I believe it’s their program that uses red light/green light, and then plays green light/red light and purple light/yellow light, and just really pushes kids to develop these skills over time. So I don’t think anybody knows specifically why imaginative play is so closely linked to it, but that’s presumably why imaginative play, open-ended play builds executive function in that way.
TS: Now, Mark, when we were talking previously—I’m using my working memory here—you talked about ADHD as a developmental delay in executive function. So first of all, I found that interesting. I’ve never heard it defined quite that way before, so that’s helpful. Now are you able to work with people such that this delay is overcome, and how do you do that?
MB: Well that is a huge discussion and I think—it’s always important to start by saying that just because we can see ADHD as a developmental delay does not mean that children are going to outgrow it if we just step back and watch. There are some kids who can outgrow ADHD, but the ones who do it do it over the course of all of childhood. Even before I talk about intervention, I would say that just to show—sort of the flip side of the research of showing the positive benefits of executive function is recognizing that under-managed ADHD children don’t have issues just in school. It affects school, it affects their social lives in some kids, it affects their physical health in other kids because it affects any part of life that requires management and keeping track of yourself, in essence. Under-treated ADHD is actually a very wide-ranging developmental disorder because of that.
The intervention is more complex than just—the goal is to definitely catch kids up, but because ADHD is first of all a proven medical disorder, there’s no doubt it’s a medical disorder at this point in time. The genetics of ADHD are almost as strong as the genetics of height. We have to start from the premises of medical disorder, which doesn’t mean we need to intervene medically, but we just have to understand that it’s not anybody’s fault. It’s not the child’s fault who has it, it’s not the parents’ fault, it’s not society’s fault. So catching someone up, like you said, is 100 percent the goal, but there’s no one intervention that’s going to do it.
Broadly speaking, when I try to lay out a plan around ADHD, there typically are educational interventions kids are going to require, there are some combination of parenting supports and behavioral interventions that are going to teach them some skills. You’re going to teach them, for example, some people think as people get older—time blindness, as I mentioned earlier, that the ability to picture time is part of executive function. Some people feel that time blindness is actually the core deficit in ADHD as most people get older. So you have to teach them how to picture time and manage it differently. So the second piece are the behavioral interventions.
A third piece, which I think is an important reflection even for today’s—the reason I even touch, I only touch on ADHD in the new book, but I think it’s important to reflect on it, because it’s like a mirror you can hold up to see why executive function is important in so many aspects of life because the third area of life ADHD tends to impact is just healthy living. Anything that requires a routine and self-management skills to sustain over time is harder to do if you have ADHD, but it turns out they all impact ADHD also. So ADHD tends to lead to poor sleep patterns, but poor sleep patterns worsen your ADHD. The same thing happens around nutrition, and exercise is one of the most useful things for kids with ADHD to do regularly, but for various reasons they often fall out of exercising regularly. So the third piece of the picture of managing ADHD has to do with just general health. Which, again, for today’s discussion is just worth reflecting on for a second even without ADHD, because you’re seeing what happens when kids have poor executive function.
Then it’s only fair to mention, even though it’s not really a discussion for today, that the ADHD medications themselves are just—most of which you read online is fairly misleading and the medications, when they’re used appropriately, have been shown to be very safe and effective over almost a century now. So we can’t necessarily teach everybody these skills just through instruction. Some people because the underlying issue is medical end up trying the medications for sure.
TS: So first of all, I think it’s very important to hear and understand that ADHD is a medical disorder. You seem to feel that that’s incontrovertible at this point. I didn’t know that, so that’s very important for me to hear. Oh, that’s not because someone wasn’t given the right environment or something like that. Now another thing you say in the book and you say this just as a small, almost in passing, that it’s relatively consistent over time the number of people who actually have ADHD. You say it’s 1 in 20. I had the feeling that in the last couple decades, more people have ADHD than ever before. But it sounds like you don’t believe that’s true.
MB: Yes, studies of ADHD haven’t really shown that to be true at all. There have been whole books that have come out reporting that certain countries have lower rates of ADHD, and really the research says it’s a relatively consistent rate of ADHD. It’s around 1 in 15 kids, and then some people outgrow it so the number goes down as you get into adulthood, but it’s pretty consistent across cultures, across time, across countries. Now the catch with ADHD is it is clinical medicine, there’s no test for it yet. Again, to give the whole picture, there’s a ton of discussion, appropriately, about the fact that it is over-diagnosed in parts of the world—in parts of this country in particular. But that doesn’t mean anything about the actual rate of ADHD. Those are two different problems. If you actually have ADHD, somebody needs to give you some support because you have a developmental delay or you have a medical problem, however you want to phrase it. I guess problem isn’t a good word to be using, but you have a medical condition.
But the flip side of that is that there’s actually other types of ADHD that are often under-diagnosed. I haven’t said yet that what we used to call ADD is actually now just considered part of ADHD, it’s somebody who has the more internal difficulties with executive function. So they could be getting reasonable grades, look from the outside like they’re doing pretty well in life, and inside just be totally exhausted by having really poor executive function. Poor time-management skills, constant forgetfulness, constantly living with their own careless mistakes. So that while on the one hand we certainly should be looking into how we can cut down on where ADHD is being over-diagnosed, which is most often is in kids who are misbehaving, the flip side of that is we also have to look at places where ADHD is under-diagnosed because people are missing the subtler, more internal symptoms of it. The stereotype—it’s not always true, but the stereotype is often smart, well-behaved girls with more mild ADHD, it just gets missed entirely.
TS: All right, well I know I’ve been talking a lot in this conversation about your work with ADHD because I find it so interesting, and also how it led you to this through line of supporting executive function and its development through the early years into teenage years and young adulthood. One of the things that impressed me in your new book, How Children Thrive, was this type of back-to-basics approach that you use to parenting again and again. That even though we’re in this time of new challenges, whether it’s video games or cellphones, you have a quote in the book, “Parenting in the Digital Age means the same thing it did in the Stone Age.”
I think that a lot of people would find that surprising. They think, “Oh, we need a whole new set of skills now because our kids are rushing to their electronic devices.” But you’re saying no, there are certain basics and those basics develop executive function. So if you were to summarize what you think the basics are of—you could call it just good parenting according to Mark Bertin, what would they be?
MB: When I say it’s the same as the Stone Age, the foundation of it is always going to be stable, loving relationships at home. Just a relationship that is warm, and positive, and makes you feel valued is certainly the beginning point, which obviously doesn’t specifically—that has almost more to do with a more global concept of resilience, that’s not specifically executive function, but that’s the foundation of it. What I think sometimes gets lost is that that really has to be equally balanced with guidance and limit setting, which is something that directly relates to understanding executive function. Young kids who don’t have a strong brain manager aren’t necessarily going to make the greatest choices around behavior, or food, or bedtime, or anything else, so we have to recognize that at home it’s a balance of overall positive feedback with very clear limits when those are appropriate. Then the second piece of—and that is a huge first step and obviously that is something that’s been true forever, but I think for a lot of subtle reasons [it] gets lost in different ways. That’s the starting point.
Then the second piece is when we look at what sort of activities really promote healthy child development, thankfully a lot of it has to do with play time, more open-ended downtime, not over-scheduling, letting go of some of the extra stuff. Letting go of the extra stuff that’s causing us stress and pressure is often helpful. There’s often external pressure that we have to do more and more and more for our kids, and yet family time, and play time, and outdoor time are often really what our kids need most from us so that they’ll do better in school, in particular. Language development is really important for kids. Where do kids develop language? They develop language from talking to adults, from reading books, from really old-school stuff. So when you tie all that together, especially in early childhood, you see a lot of things that can be done in a very unpressured way and are really going to be what really—from a research point of view if nothing else—sets your kids up for school success.
In terms of this whole hugely evolving discussion about technology, I think it’s all about balance, and we just have to step back and look at the fact that just because something is new and cutting-edge doesn’t mean it’s completely benign. But technology itself is just a tool. It’s one we could use well and it’s one we could use poorly, like any other. In childhood in particular—again, I said it earlier—kids are the ones with immature brain managers. There’s no reason to assume any more than if we just threw them the car keys at 10:00 and said, “Go take a drive,” there’s no reason to assume that they’re going to manage technology while on their own.
They just need our supervision for all the very real and very negative research about the impact of technology on child development, which it’s important to familiarize yourself with as a parent. To recognize that this is real, this isn’t just some new form of music that’s supposedly going to wreck kids and never turns out to anything. There’s a real impact of technology on child development, and yet the research is actually quite reassuring. It really just says that when we recognize that parents need to be moderating it, and setting limits, and guiding kids to healthy use, then kids do fine. To come back to what you said in terms of why we can tie old-school parenting to modern parenting, it really comes down to just the recognition that kids are kids and just because they want to be on their smartphone 47 hour—I think I did my math wrong, I was going to say 47 hours a day. I guess that’s not possible, actually. But the point is they might want to be on it all the time, but it doesn’t mean they should be or that’s what healthiest for them.
TS: In terms of setting those limits, I’ve seen so many parents—I’m not a parent myself, but I’m an aunt to many young nieces and nephews and have friends with small kids. I’ve seen so many times parents get so frustrated with their kids who are sneaking into their purse to get their cellphone, or sneaking off into the room to go play video games, or under the table are playing with some kind of device. It’s such a battle. How do you draw a limit and not turn it into a battle?
MB: There’s no quick answer to that, except broadly speaking I would say there’s several different things. One is all of it starts with our own use as parents. We need to make sure that when we’re with our kids, we’re just with our kids and not on our phones. Partly because it’s so important for children to have that relationship without technology getting in the way, and partly because we’re demonstrating something when we do that. Then when it comes to actually setting limits around technology itself, it’s easier if you start younger, for one. So you just want to set the guidelines. There’s a whole other discussion for kids who are out the other end of this and are already teenagers. But ideally you just start by establishing, “This is how we live at home,” and it’s a lot about healthy living. We don’t do it all the time and these are our guidelines that you set. So when we have down time we have down time, maybe you do some stuff before dinner. So some of it is just building it into routines at a very young age. It’s really useful to have a tech bedtime in a household, it’s useful to keep screens out of the bedrooms as much as possible.
So some of it has to do with establishing a lifestyle young and then the rest of it has to do with—it’s really challenging, I don’t think there’s any black and white answers. But just has to do with behavior management. Really has to do with first of all spinning it around so it’s a privilege to be earned, so it’s not entitlement. It’s something if you use it responsibly you can have more, and if you use it irresponsibly you’ll get less. I wish there was a less stark sounding answer, but a lot of it does have to do with that. Instead of letting it become a game, you just establish your expectations as a parent. Yet it’s easier to say that than to do it. A lot of it is just doing our best and then adapting to whatever happens. Parenting is rarely ever perfect and clean; it’s much easier to set out general advice that is a good starting point, and then it’s all about dealing with whatever imperfection and mess follows next sometimes.
So I don’t want to make it sound like it’s easy to do it that way, but conceptually there isn’t anything else to look at. It’s all about living the lifestyle you want to live. This is how I think technology is healthiest in my household and so we’re going to live—same way you tell somebody we’re going to brush our teeth, we’re going to get outside once in a while. Whatever it is, this is how we live. Then the other side of it just has to be that recognition that if we don’t figure out a way in each individual household to set some boundaries and limits, there’s no reason to assume that most kids are going to themselves.
TS: Now, you’re a father, right, Mark?
MB: I am, yes.
TS: I’m curious, of all the things you know that work, what’s the hardest for you to put into practice as a dad?
MB: Around technology?
TS: No, just in general. You know all this stuff now, you—
MB: It’s all hard to do in your own household.
TS: You coach so many parents—
MB: No, I would say—it’s such a general question, I’m not even sure where to ask. Some of it is just that it’s hard to stay consistent. In spite of knowing better I still get hooked by stuff going on at home and things my kids do that make me feel worried, or anxious, or just generally annoy me, and then I’m sucked in and then now I’m doing all the things I would hope somebody else wouldn’t do. So it’s definitely part of parenting that you’re going to get knocked off balance emotionally, and that’s something I’m never going to avoid entirely. Technology is—even being as clear as I can with the boundaries, it’s a stress. I think it’s a stress for many parents nowadays, and I get sucked into that discussion too where I might—a subtlety here is that for some kids, the more black and white you are about what’s appropriate, the less they’re going to think about it. It’s almost like a weight off their shoulders to not be constantly worrying about how much is OK or not OK. Yet it still becomes a discussion and a battle at home sometimes. I don’t know if that answers your question, it was such a—
TS: Well, I put you on the spot a little bit but I was also just—
MB: No, I don’t mind being on the spot. But yes, those are a couple of areas that are challenging at home, and I think the thing about parenting is that it always changes over time. So just when you think you have a handle on this week, you have next week to deal with. Which I don’t mean to say that negatively, I just mean there’s always—it’s a blast, but I love nothing more than time with my kids and yet there’s always some new thing to be dealing with. But that’s just what it means to be raising kids.
TS: Now, Mark, you mentioned briefly mindfulness and mindfulness meditation and how it affects our ability in terms of executive functioning, and that mindfulness meditation supports healthy executive functioning. Can you explain to me why that’s so?
MB: Absolutely. I would just think as you were saying that I realized that we have actually—even though I haven’t laid it out—touched on several of the different areas that if you want to organize your thoughts around what promotes and what relates to executive function in childhood. It’s the activities we pick with them, the environment we’re raising kids in, education is a piece of it, what’s going on at school. So mindfulness to me, the way it relates is this: one of the more—I’ve been saying for years it’s cutting edge, but I guess most people are familiar now with the concept of neuroplasticity, I hope, which is the idea that anything we do repetitively actually physically rewires the brain. It’s a very different way of thinking of brain development, different than I was taught growing up. Definitely growing up, but different than I was taught in medical school, even. That the brain basically evolves like a muscle, we can’t change everything.
When it comes to the broader picture of what it means to practice mindfulness, it’s not even meditation we want to be thinking about at all. The broader practice of mindfulness is one that’s meant to help us handle the challenges of life by helping us stay settled when pressured, helping us stay more focused. I normally think about mindfulness of having an aspect that has to do with focus and things, staying settled. Another aspect that has to do with self-awareness or awareness and working with habits. Then a piece of it has to do with compassion, this broader sense of how it impacts our world. So when you look at mindfulness and executive function, it’s really one of the more direct ways we have to, in essence, work on self-management skills. Because what’s mindfulness aiming to do? The intention is to help you manage life, in essence. It’s to help you manage life when you feel unsettled, manage life when you feel settled as well. It’s meant to build skills like executive function, like focused attention, managing your emotions, pausing and taking a broader perspective. All of which is very executive function related.
So one of the reasons I ended up involved with this book and one of the things that just clicked to me, both personally and professionally, is I was introduced to mindfulness myself many, many years ago during my medical training fortuitously. As my career has evolved, there’s this evolving research study, the [Inaudible] executive function, there’s evolving research about mindfulness which does also relate to executive function and executive function as a developmental path. All of it just comes together and is really all just different aspects of the same concept. We really need to actively make the choices in life that help us build skills that keep us resilient and that are going to support us when the challenges come up. The flip side is I think I’ve been overemphasizing challenges and also to enjoy the good times too, to really not overlook all that as well.
TS: One of the connections that this conversation has made for me is a few times you’ve talked about how as children develop, they can learn more and more self-management skills, so they can delay when needed, they can manage their emotions, etc. You also talked about executive function as being this ability to be an orchestrator, and being able to bring a lot of different planning pieces together and plan into the future, having a good sense of time. So this connection between how we manage ourselves and our ability to manage others seems really important. That if we’re able to manage ourselves, our own emotions, we’re going to be much more capable of being able to manage a lot of complexity in our environment and even other people.
MB: Absolutely. I think that’s a brilliant point and it relates directly—when we talk about practicing mindfulness, we’re not talking about a self-help skill set here. Mindfulness, just as an example, this directly relates to what you just said. So starting with mindfulness, because we were just talking about it, I think it’s important to think about mindfulness as something, not as self-help, but the assumption is that because we’re more settled and managing our own lives that influences everyone else around us. That influences how we interact with everybody. That changes way more than just our own experience. You could see all of executive function that way because that’s what life is.
In fact, one of the academic constructs of executive function—which is from a researcher named Russel Barkley—Dr. Barkley calls it almost the foundation of ethics and morality. From his point of view, the reason we developed executive function, again, wasn’t to take care of our own lives independently, it’s because we need a pretty complex brain manager to get our own needs met in a way that is culturally, environmentally appropriate. These are the skills we use that engage with the world, that help us meet our future needs, our present needs in a way that follows the rules and takes into account other people’s perspectives. So all of executive function can definitely be tied not just to our own well-being, but it impacts hugely how we interact with everyone around us as well.
TS: Which leads me to my final question, Mark. Here you work day to day with children, helping parents, helping families, and you also write these books, your new book How Children Thrive: The Practical Science of Raising Independent, Resilient, and Happy Kids. What’s the cultural contribution you’re hoping to make with your work?
MB: I think my intentions, the reason I want to do all this work is to—they are different but related. I think when it comes to my writing in particular, I really want to help people cut through the stuff that’s confusing. I think there’s just way too much overwhelming information in terms of volume, in terms of fearfulness in the world right now. Really I’ve always loved writing, and I want to be able to get the word out of ways to cut through it all, live a simpler life, do the things that really do make it more likely our children are going to succeed, and make things more enjoyable and manageable for both parents and children. I guess in many ways that’s kind of what I’m doing day to day in my clinical practice too. The goal is always to try to make things easier and to help people get to where they want to go, whatever it is they’re trying to accomplish.
TS: I’ve been talking with Mark Bertin, who’s the author of the new book How Children Thrive: The Practical Science of Raising Independent, Resilient, and Happy Kids. Mark, thank you so much for your good work, thank you.
MB: I appreciate it, thank you so much for taking the time to talk.
TS: SoundsTrue.com: many voices, one journey. Thanks for listening, everyone.
