ADHD at School: What Actually Helps | Richard Gallagher, PhD

How do you help a child with ADHD stay organized, on task, and confident in school? Richard Gallagher, PhD, a child and adolescent psychologist at NYU Langone Health, shares groundbreaking research on organizational skills training for children with ADHD—a behavioral treatment that’s changing lives and improving classroom performance. This episode dives into how executive functioning challenges manifest in real life, the strengths (and limits) of technology, and the power of parent training and therapeutic coaching to help children thrive.

Dr. Richard Gallagher is Associate Professor in the Department of Child and Adolescent Psychiatry at NYU Grossman School of Medicine, and Director of the Organization Skills Program.

🔍 Topics Covered

00:00 Introduction
00:19 Current Research on Organizational Skills
01:06 Executive Functioning and Practical Interventions
02:37 Impact of Interventions on ADHD
04:41 Expanding Research and Brain Connectivity
05:08 Medication and Organizational Skills
08:11 Technology in ADHD Assessment
15:39 Effective Parenting Styles for ADHD
23:10 Non-Pharmacological Treatments and Future Research
25:58 Conclusion and Final Thoughts

📚 Related Resources

👨‍⚕️More about Dr. Richard Gallagher
🔬 NYU Child Study Center
📘 “Organizational Skills Training for Children with ADHD” by Richard Gallagher, Howard B. Abikoff, and Elana G. Spira 
📝 CHADD Parent Training Resources
📈 CDC ADHD Parent Guide

🙌 Support & Engage

If this episode was helpful, please like, share, and subscribe to support the series and spread awareness about evidence-based ADHD care.

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Executive Producer: Jon Earle

Transcript

DR. THEA GALLAGHER:  Welcome to the Insights on Psychiatry podcast. I'm so excited to introduce our guest today, Dr. Richard Gallagher, who is an associate professor in the Department of Child and Adolescent Psychiatry and the Psychiatry Department here at NYU Grossman School of Medicine. Dr. Gallagher, thank you so much for being with us today. 

DR. RICHARD GALLAGHER: Thanks for having me. 

DR. THEA GALLAGHER: Can you tell us just a little bit about what you're working on right now, like an overview of your current work? 

DR. RICHARD GALLAGHER: Well, in terms of research work, the research is in two areas right now. One that we've been working on for a good number of years with the person that helped initiate this work, Dr. Howard Abikoff, his work on understanding organizational skills as it affects young kids in terms of their performance in school and also their activities at home related to school, which has been a real significant problem that parents are concerned about, teachers are concerned about, and gets the kids pretty concerned as well, because it really does interfere with how well they're able to manage all the demands. And they spend an awful lot of time in school. And so they really can get quite stressed and distressed about things and not be very clear about why it's happening.

DR. THEA GALLAGHER: And when you're talking about organizational skills, are you referring to executive functioning skills as well, or like kind of a subset of those executive functions? 

DR. RICHARD GALLAGHER: We've been thinking about it as practical reflections of executive function skills. We started our work about a little over 18 years ago and looking at a fair amount of work that had been done on executive functioning that was really rather abstract. And there were ideas about saying, well, let's train kids on different kinds of tasks that we think will improve their attention on computer games and other things like that and they really did improve the kids' performance on computer games, but didn't really deal with what's going on in the classroom. So what we started looking at and we started measuring this, we developed the first measure in this area, and found out that you know they were pretty variable in how well kids were doing with regard to just knowing what their assignments were and having methods for keeping track of that. And then also managing the materials. We find out kids are having their parents saying, why aren't they bringing home what they need to bring home? And the teacher's saying the same thing. And finding that's a problem and you know finding backpacks that are exploding. And then we also found that there was a lot of issues with regard to time management and just being aware of how much time it takes to do things. And then the whole prospect of planning, you know knowing exactly to do a book report or to be able to do your homework, what are the steps required to do it? With some kids being really quite unclear about that? 

DR. THEA GALLAGHER: And some of these practical and behavioral interventions have been found to be effective? Is this the current work that you're doing? 

DR. RICHARD GALLAGHER: Yes. Again, what we've done over time is we've been working first with kids with attention deficit hyperactivity disorder and our focus has been on elementary school kids. And we did find in developing a treatment, we had a very nice, beneficial grant, basically just a treatment development grant, and put together ideas about how to teach kids skills, how to get their support from parents using behavior management strategies, and how to be able to get their teachers to support the kids as well. And through pilot testing and then a randomized controlled trial we found incredible positive results with the kids really changing quite a bit and that it also did not only show up on their organizational skills, they got better at tracking assignments. They got better at remembering to bring home their papers, and then managing time was better as well. But we also found that there were outcomes in the classroom. The teachers said that they're being much more productive.  The teachers rated them as being much more close to what they should be doing with regard to their meeting demands and their grades. And we also then found at home that the parents said that there were many fewer problems with homework and that there was a lot less family conflict. 

And then in the long run, we also found we tracked the kids into the next school year they had much improved attitudes towards school and teachers. So we think we kind of put them on the right track with this work.

DR. THEA GALLAGHER: I imagine it also bolsters self-efficacy for them as well because if they're able to kind of meet the demands of both the school requirements and the home requirements that they'll feel better about themselves in the long run as well. 

DR. RICHARD GALLAGHER:  Yeah, we hope so. And we do think, you know again, also with some of the work with older kids, with middle school and high school and even some college students, that an awful lot of kids with ADHD that have these troubles end up really getting disengaged with school, thinking that they can't keep up and they don't quite understand why I'm having such trouble and why can't I remember to write things down, you know stuff like that. It has a really, we think a very negative effect on the outcomes later on in life. We've been able to do more work with this, and our most recent study has looked at expanding it to kids that are not only with ADHD but other conditions where they might have these organizational deficits. We've done another recent randomized controlled trial where we've looked at their brain scans in terms of functional connectivity before and after treatment, and we have found that we've changed their brains in terms of that measure. 

DR. THEA GALLAGHER: I'm wondering for these individuals that were in the study, were they also on stimulant medication or did you control for that? Like some people were and some people weren't? Did it work as effectively with both groups? 

DR. RICHARD GALLAGHER: We didn't control for it, and it did work as effectively for both groups. The kids all had to enter with organizational issues, and that was even with medication. We had done also a study where it was an interesting study looking at the effects of medication on organizational skills and found that in a crossover design, kids were their own controls, that when they were on medication they did show improved organization. But the results and the effect sizes and the number of kids that went into the normal range was not as much as we found in the psychosocial intervention where we taught the skills.

DR. THEA GALLAGHER: It seems like if you were a psychiatrist or a clinician  therapist working with a patient knowing that maybe this combination of medication and skills could be really effective. And is this in a manual or are you working on this manual? 

DR. RICHARD GALLAGHER: Well, we have a manual and it's been published. It's in a book that's available that spells it all out and we've been also doing a lot of workshops around the country with regard to this. In combination with another person, Dr. Maggie Sibley at University of Washington, who does this work with middle school and high school kids. So there's a whole path of work that's been done and there's another group that's been doing this with these efforts with college students. So there's like a whole collection of treatments that are available that spell out you know what to do when people have these kinds of difficulties. 

DR. THEA GALLAGHER: Wonderful. Can you give our listeners the title of the manual? 

DR. RICHARD GALLAGHER: It's called Organizational Skills Training for Children with ADHD: An Empirically Supported Treatment.

DR. THEA GALLAGHER: Wonderful. Very straightforward, to the point, literal. Good. 

DR. RICHARD GALLAGHER: And we're actually working on a revision because the most recent effort that we did, partly inspired by COVID, when we couldn't bring kids into the study because of the pandemic and the isolation and restrictions, we decided to deliver it all virtually and see what you can do with kids with ADHD and other conditions when they're being treated virtually. And the results have been very, very similar. So we're actually making revisions saying, well, you don't have to have people come to your office. You can deliver it to them across the state. 

DR. THEA GALLAGHER: I think it's exciting too because I'll work with parents and they'll say to me, hey, you know my child was diagnosed with ADHD and I'm really nervous about the idea of medication. I wish there was something else that was as robust, and it sounds like you're doing the work with some of these behavioral interventions that could be as good or work in tandem with medication. 

DR. RICHARD GALLAGHER: Yeah. And that's the hope that this will be able to be done. We're focusing on this one specific area. Interestingly, there's other areas that are also finding things that can be done and there's a lot of good development in the last number of years on kids with ADHD and the psychosocial treatments that are effective. 

DR. THEA GALLAGHER: With the rise of a lot of digital health tools and we were kind of talking even about access to care and virtual dissemination, how would you say technology is enhancing the accuracy and accessibility of ADHD assessments in children, if at all?

DR. RICHARD GALLAGHER: Well, again, so the trick with regard to ADHD in terms of things is there's never been found to be a single test that finds out if a person has ADHD, with the exception of really careful history and with really good rating scales as collected by parents and teachers. I think everybody needs to remember that persons with ADHD are not ADHD all the time. And that's really important to be talking with teachers and parents who often will say things like, well, you know this kid can play video games or play with Legos for hours at a time and not lose focus. It's really on tasks that are less interesting and that you have to really kind of get a sense of what that's like. 

DR. THEA GALLAGHER:  And what those tasks are. 

DR. RICHARD GALLAGHER: Right, you know for a specific individual. Again, some kids love to read. They’re actually, we have some troubles with some cases of kids we work with where the teachers are saying, yes, this is fine, but the child's not doing math and not doing social studies because they have a book hidden behind their other workbook because they're really diving into reading and they're staying with that. So it's a process of making sure that we are being careful. With technology, we can find out with some of the different measures of is somebody really attending well or not, you know some different tasks where they're watching something, and we can get better at that process and see what waxes and wanes. But we do also need to recognize that we have to maybe take multiple samples because sometimes when kids can do it relatively well for one time but maybe have trouble drifting at another time. Again, at the same time, also really making sure that we have a good understanding of the history because I tell trainees a fair amount that attention is like the fever of psychiatric disorders. You know persons with schizophrenia have attention problems. Persons with depression have attention problems, with anxiety. So is this truly a condition that's been around for a long time and is not due to some of these other factors? 

DR. THEA GALLAGHER: Trying to understand if it's symptom or cause?

DR. RICHARD GALLAGHER:  Right. Right. 

DR. THEA GALLAGHER: Is there anything with technology that you think is enhancing it or the ability to kind of disseminate or utilize a number of assessment tools that a patient could fill out and then kind of those together would bolster the diagnostics? 

DR. RICHARD GALLAGHER: I think so and I think that, again, if there's information that's gathered with large data sets, that we can begin to find more clusters and some variations that I think are important. Technology itself, as I said, I think it can be useful, but we have to be pretty careful because, for example, one of the different recent interventions have been done using technology. There's been one that's actually been approved by the FDA, the EndeavorRX it's been called or by Akili. And they've got a good randomized trial that got them to be able to get FDA approval because it's safe. And it also resulted in attention improvements. That was their target. But the attention targets that they were able to do was on a video game. They got better at a video game in training in this video game. So we often get a little bit too enamored of technology because those same kids really didn't change their classroom behavior. It really didn't carry over too much into their home behaviors.

So I think we have to be cautious with regard to this process of technology as a panacea.  You know in the area of keeping track of things, many school districts that we dealt with and some private schools said, okay, for elementary school-age kids, we're going to have them use electronic methods for keeping track, and we're going to start having them doing things like a calendar. Many schools stopped doing that because they found that the kids couldn't handle it, that they really needed to keep using paper and pencil at that age. Middle school, high school, it's a difference. So I think we need to keep diving in and using it as a tool, but not necessarily finding it as a tool that's going to be the answer. 

DR. THEA GALLAGHER: It might not be as generalizable as you hope. Now, with regard to assessments in children with ADHD for some of our listeners, what are the assessments that you recommend? 

DR. RICHARD GALLAGHER: Well, again, a really good history. You know find out about their development, you know really see about tracking things and getting a sense of when did the issues with attention start to show up and where do they show up? So a good functional assessment of going to church, going to other services, being at school. You know when does our attention concerns present and for how long have they been present? Some of the rating scales are useful, and they can kind of highlight that this child, as described by a parent, as described by a teacher, is looking different than the norms that are present. And so I think that that's helpful. And we would say that sometimes, if there's real learning concerns, neuropsychological assessment can be useful. But we don't want to say, and people have said that this, kids all need a neuropsych assessment. No, you just need a good, careful history with some rating scales and an interview to also talk with a child. You know look to see. Is this child preoccupied with anxiety? Is this child showing some mood issues that might be interfering? And can we make sure that we're not saying that that's the only cause of attention issues.

DR. THEA GALLAGHER:  It does seem like with ADHD and even autism spectrum disorder that it's becoming more accessible for more people to diagnose. I feel like there was a time where it was like, you have to get a full neuropsych assessment. And then I feel like access to maybe even the behavioral interventions was more delayed. So what you're saying is actually kind of a good clinician who is taking a good history and looking at the symptoms, then maybe bolstering it with some other scales as well. 

DR. RICHARD GALLAGHER: Right. And again, not doing things you know in the office in 20 minutes. You know that happens too often because, again, if a kid's anxious about being in the office, they might not be very inattentive or hyperactive. And again, it doesn't necessarily, if it's also seen in that time, it's like, oh, okay, the child might be anxious and be more restless. So you have to be able to make sure you're seeing things across situations and for a persistent period of time.

DR. THEA GALLAGHER: I think it's such a fascinating thing even with ADHD and anxiety because it might be that your organizational skills or deficit with organizational skills are increasing your anxiety, which then, again, it's a combination or the other way around. 

DR. RICHARD GALLAGHER: Right. And if we take a look at one of the largest studies, the MTA study that was done a number of years ago, people have been tracked for a long time. That was a study with like over 500 kids. The frequency of comorbid ADHD and anxiety was about 25% to 30%. So a fair number of people have both problems. 

DR. THEA GALLAGHER: I think for a lot of clinicians, you know wanting to be able to treat both disorders effectively and in concert with each other could be a good thing too. 

DR. RICHARD GALLAGHER: And that's a real challenge for my colleagues in psychiatry, I know, because the usual stimulant medications for treating ADHD can raise anxiety. And again, sometimes the anti-anxiety medications make the kids less inhibited. And so there's a real balance that people have to work with. 

DR. THEA GALLAGHER: Yeah, threading that needle. And I want to talk a little bit about parenting styles. So how do different parenting styles affect development and management of those ADHD symptoms in children? And what guidance can you give to clinicians involved with families? I know most people who are working with children or adolescents are likely working with the parents and the teachers as well, but maybe talk about  the parenting styles and then the relationships. 

DR. RICHARD GALLAGHER:  Okay. Sounds good. I teach a class on parenting NYU undergrads. I've been looking at this and we kind of investigate that fair amount in the literature. So you know most people will say that the most beneficial way of being parenting is having a good balance of limit setting and then also being connected to the kids. And so with regard to parenting style, it's important for parents to be able to, I think, recognize the nature of ADHD and be clear about it because it can look volitional. You're not paying attention on purpose. You know, sit still. Why don't you just listen to sit still? And it can really turn into a situation where the parents get overly angry and really, in some ways, insulting to the kids. Like you're just not doing things the right way and why, in some ways, a bad kid. 

It doesn't mean that they should excuse it, but it would be important to be able to say, look, we are understanding this. We want to have you cope with this. Let's see what you can do about getting better. And I like to have parents really think a lot about being careful where they spend their attention, to not really focus a lot on the negative actions, but to be pretty thorough with regard to praising and noticing things with either a magnifying glass or a microscope. Sometimes you really have to look at tiny, tiny pieces of behavior that are in the right direction. If kids are sitting down to do homework and they're starting to get ready. They sit down, they pull out the math workbook, and they're doing a good job, and then they get distracted a little bit. Parents will often get focusing a lot on the distraction. You know don't be looking for another pencil. Don't do that instead of saying, you know I'm glad you're sitting down. I'm glad you got your book out.  Now let's please start looking at the problems themselves. So it's a process of really in their own controlling their own intention. 

DR. THEA GALLAGHER: And maybe also understanding a little bit of the nature of ADHD as well. I think if you understand how it works, you might have more empathy or patience around the things that seem maybe just like, oh, you could easily control this distraction. I think the more understanding kind of creates that empathy. 

DR. RICHARD GALLAGHER: I think it's an interpretation that's accurate. I'm not sure completely. I try to suggest that people who are also people that have been diagnosed as adults and even later in the adolescent years, it's kind of like say, you want to be able to understand things, and I want parents to do that with a person with ADHD is often fighting their brain. So we have this pretty clear indication from studies that everybody's brain switches attention all the time, that it's oscillating. And that persons with ADHD don't have the other strong mechanisms in other parts of the brain that help control it, saying, no, no, no. Don't pay attention to that little noise and that humming that might be happening. Stay focused. And persons with ADHD don't have the strength of those others. So their brain is saying, okay, let's find something interesting. Let's make sure that we're paying attention so that we don't run into any danger. And it's like this is going on down subcortically, and they don't have the power to kind of say, okay, stop that. Stop that. Stop that. So their brain is naturally drifting. And I think that it's helpful to have people recognize that you know this is a natural process that's a little bit out of control, and you might have a good bit of trouble controlling it. You know people say, why don't you just pay attention? And it's like, well, if you have an attention disorder, how do you pay attention to your attention? I don't think you can do that. So I think we have to be giving people as much psychoeducation as possible. 

DR. THEA GALLAGHER: Absolutely. And I feel like I've seen some things online about maybe moving toward a model where it's less about people with ADHD having to change completely for the world around them and the world kind of also understanding and kind of maybe even encouraging maybe some of the creativity or other things that come with ADHD. What are your thoughts on that? Because I think when it's looked at as like, oh, this is a problem that needs to be fixed, or, this is just like a different, maybe kind of a set of skills or a different layout of the skills.

DR. RICHARD GALLAGHER: I think that's valuable to recognize. I think that it's certainly valuable in the long run. We have, again, in the United States, I would say, primarily, we have a pretty strong emphasis that says that with regard to, let's say, education, the path to education is doing a fairly heavy work with studying, with reading, with writing. And we're kind of like losing, I think, in some cases opportunities for finding people that do things really, really well, but they do things with their hands and through movements. And I think we often lose out because there's this kind of orientation that says, well, if a person goes in the direction of vocational education, as opposed to academic education you know in high school, that that's not valuable. That's not the right way to go. And I think that that's the wrong information. And I think that we should be making things a bit more flexible. 

DR. THEA GALLAGHER: Do you have hopes for even I'm thinking of things like ChatGPT or Copilot for maybe people with ADHD and maybe some of the tedium of school and how those AI services can maybe help with even some of the tedium. What are your thoughts on that? 

DR. RICHARD GALLAGHER: I think it has to be within reason. I think we have to be keep looking empirically. You know we have information that has found, for example, that with people not learning to deal with handwriting and cursive writing, we now run into college students who can't read cursive. And so it's okay. Is that a good thing or not? Perhaps we need to wonder about that. And I think that we might have to watch out because if ChatGPT is doing the writing for you, you may not learn how to write terribly well. And so again, I think it can be used to enhance things, but I think we want to make sure we don't let people lose their skills. And accommodations have to be careful with the work that we do because of clinical referrals, we often have gotten college students that have been asked to take leaves of absence because they weren't organized. Again, from some of the finest colleges in the country, these kids are smart. And in some cases, we found that what has happened is that there were so many accommodations, and their parents were kind of like watching over and saying, I'm going to check the school portal. I'm going to keep making sure what your due dates are. I'm going to keep doing these different…the kids get to college and it's like, I have no idea how to do this. So I do think we have to be careful with regard to how much reliance we have on other tools besides developing your own skills.

DR. THEA GALLAGHER: You talked a lot about already the non-pharmacological treatments for children with ADHD. Is there anything that we haven't covered about those that you want to make sure we discuss? I know you talked about organizational skills. How about executive functioning skills overall? Anything else that's promising there with regard to behavioral interventions? 

DR. RICHARD GALLAGHER:  Well, I do think that there's work that's being done and it's at different ages. We recently wrote a paper that was a clinical paper for people to think about pinpointing at different stages of life, what could be appropriate. What looks good for ADHD in the beginning is, in addition to looking at possibly psychopharmacology, is for good education of parents. So there are some good programs that, again, have been tested that lead parents to be much more likely to pursue behavior therapy as well as medication considerations when they get…it's been called boot camp, but it's now called Get Ready, where there's about four sessions presented to parents in groups right after the diagnosis saying here's what we understand about this condition and here's what's available.

When we move into elementary school and when the peer group becomes more important, there are a couple of different social skills interventions that need to be looked at carefully. They're offered a lot, but the ones that have been tested have been done primarily through teaching parents how to coach their kids on play dates, to be able to be more thoughtful about the other kids, to be a little bit less impulsive, to be careful about interrupting other kids. And then at the same time, these issues around helping parents work to negotiate with their school. And then the organizational skills we think is important around that age as well. 

As kids get into adolescence, again, the organizational efforts have been a bit more on executive functioning in addition to the basics of organization, but more about also how to think about studying and how to interact more effectively with parents around those issues. That's been helpful. And then there's new work that's been looking at the whole issue around emotion regulation, which is kind of responding when you're distressed and managing your behavior more effectively. And interestingly, again, that work has been facilitated by working with parents as the first step where it's like, okay, we want to make sure that you have good emotional regulation skills when you're dealing with your child. And then now we'll work on teaching your child these different strategies for recognizing when you're anxious, recognizing when you're angry, recognizing when you're depressed, and how to respond the best way when that is present. So those are some of the ones that are really showing the most good empirical support at this time. 

DR. THEA GALLAGHER: So just in conclusion, what are some of the emerging areas of research with ADHD that you're really excited about for the next decade?

DR. RICHARD GALLAGHER: Well, I'm pretty excited about these ideas about looking at behavioral interventions and how that affects brain functioning. I think that's really an important area. It is possible that this information may allow us to eventually become more prescriptive with regard to possibly the medications. You know the medications have a good number of side effects and so if there's ways of being able to pinpoint certain functional networks, that might be something that allows people to be able to have a very specific kind of help without having a lot of the side effects that come along as well. So that's one area. 

And I think that, again, the ideas about looking at ADHD and its emotional components, I think, are important as well. The focus had been on, let's quiet these people down. Let's get their behavior under control. And I think that there's much more attention for looking at the consequences of this condition and how it might impact people's impressions of themselves, and looking at things like its impact on propensity for drug abuse, propensity for depression and in fact, you know again, a further investigation has been finding that there's a lot more suicidal thinking and suicidal actions in persons with ADHD. So I think there's work that's being done to say, you know this is a much more complicated disorder than just kids being restless and people being inattentive. There's a lot of other elements to this that I think we need to expand our thinking about. 

DR. THEA GALLAGHER: Absolutely and I think with the depression piece, one of the things I've seen in my patients sometimes is a lot of negative self-talk. Like I don't do…things that are easy for everyone else are really hard for me. Why can't I just do my laundry? Why do I have this time blindness? Why can't I just be on time? Why do I feel so strongly with these reactions? And I imagine that that might kind of contribute to more depressed thinking as well and I'm hoping in the future maybe there could be an opportunity to understand the symptoms, work within them. You know we're in certain systems that need maybe more of these skills than others. But I think also then to highlight maybe certain strengths. So not looking at it only as areas of weakness. 

DR. RICHARD GALLAGHER: Right. And again, taking a look at the perspective of the weakness, I think it's helpful for people to say, you know there is something different about me, but not to be global about it. It doesn't mean I'm a complete disaster. And that's often what comes across with the messages. I think that this happens with parents. It's like you know they get frustrated with their kids and they say, what's wrong with you? Or they ask questions like, why did you do such and such? And it implies that there is something wrong with you, but it gets to be global as opposed to saying, okay, I have trouble in these certain situations. I need to see what I can do about being better at that. And I think that that's a helpful thing to kind of let's not make these things quite so global.

DR. THEA GALLAGHER: And one of the quotes I saw once that I feel like has resonated with some of my patients is that people with ADHD make hard things easy and easy things hard. And kind of I think highlighting sometimes maybe the harder things that might be harder for a neurotypical that you're able to do that come easier to you and giving yourself, I think, also some acknowledgement for your strengths and not only that focus on those weaknesses. 

DR. RICHARD GALLAGHER:  Yeah, that makes a lot of good sense. And that's a good way in general for people to probably think about themselves. 

DR. THEA GALLAGHER:  Well, thank you so much for being on our podcast, Dr. Gallagher. 

DR. RICHARD GALLAGHER:  My pleasure. Thank you for having me.

DR. THEA GALLAGHER: And thank you to all of our listeners and viewers at home. If you liked this episode, make sure to rate and subscribe on any place that you're listening or watching the podcast. Thank you from all of us at NYU Langone Health.