F.O.C.U.S

About the Presenter

• I'm Dr. Josh Hersh M.D. and I am a board certified psychiatrist
• I have been working with college students as a psychiatrist for 15 years at 3 different universities
• Throughout the years I have seen thousands of students who have presented to me with problems focusing
• Being a psychiatrist means I am often asked to prescribe medication including controlled substances such as prescription stimulants like amphetamine mixed salts (Adderall)
• Throughout the years I have seen students that benefit from stimulants and students that are harmed from stimulants
• I learned that the students that who were harmed from stimulants were mostly students who did not take adequate time to rule out other causes of focus of ADHD-like symptoms and improve life habits and academic skills

Purpose of the F.O.C.U.S Intervention

• The F.O.C.U.S Intervention was created to help college students struggling with focus problems take adequate time to understand all the things that contribute to problems focusing
• It was also created to help students try to fix their life habits and improve their academic skills before considering ADHD testing and treatment
• If fixing your habits and improving academic skills does not lead to improving your focus then it is reasonable to consider ADHD testing

Common Struggles with Focus

Do you relate to these struggles?

"I find myself constantly daydreaming"

"I feel like I am always distracted by my phone"

"I try to study but I can't remember anything I read"

Why Can't I Focus?

• The brain is a very sensitive organ and many things can impact its ability to focus on tasks and filter out distractions
• These factors can be transient (such as a relationship issue) or more long-lasting (such as a chronic mental health or medical condition)
• It's important to try to identify all the causes to find the right solutions

How your Brain is Like an Airplane

Seeking Quick Fixes

• Most focus problems are not ADHD
• Even treating ADHD involves making the behavioral changes discussed in the F.O.C.U.S. intervention
• Seeking "quick fixes" to focus problems often causes more problems in the long term
• You wouldn't want a plane fixed with duct tape so why seek a quick fix for your brain?
• Improving focus involves understanding the complexity of focus problems and making significant changes in your life

"Why should I care about all this stuff if I just want to be tested for ADHD?

I have a busy schedule and I am not sure I have time for this F.O.C.U.S Intervention"

• You may identify with the quote above
• It is important to try to address all factors that affect focus if you want to be tested for Attention Deficit Hyperactivity Disorder (ADHD)
• Not addressing these factors can actually make ADHD testing invalid and lead to misdiagnosis
• Misdiagnosis of ADHD can lead to treatments that can actually make your focus worse
• Trying to correct these factors can lead to more accurate ADHD testing and the best possible treatment

How Long Does This Take?

• This F.O.C.U.S Prezi may seem overwhelming at first
• Understanding and improving your focus can take time
• The F.O.C.U.S Prezi takes about 90 minutes if you go though it from the beginning to the end
• It is best completed in sections
• You can zoom in on topics that you struggle with and zoom out of topics that are not relevant to your struggles

Poor Sleep

Sleeping Habits

• Most students are sleep deprived!
• The National Sleep Foundation suggests most college age students need about 7-9 hours of sleep
• Most college students get only get 6-7 hours of sleep (and some, far fewer)

https://www.sleepfoundation.org/press-release/national-sleep-foundation-recommends-new-sleep-times

Poor

Dietary

Habits

Eating

and

Drinking

• What we take into our bodies has a big impact on our ability to focus
• Lack of adequate calories can cause hypoglycemia (feeling shaky) which affects focus
• Eating too much in one sitting can cause fatigue and tiredness (postprandial somnolence)
• Deficiencies of certain amino acids, B vitamins, and magnesium can cause problems with focus
• While eating sugary foods or sodas can give immediate help it can cause "sugar crashes"

Physical Inactivity

• Studies show that too much sitting and lack of exercise contribute to mental and physical health problems

https://medlineplus.gov/healthrisksofaninactivelifestyle.html

Substance Misuse

• Many substances can have significant effects on brain functioning
• Some substances can have ADHD-like effects and lead to misdiagnosis of ADHD
• Some substances may help in the short term but lead to long term consequences

https://teens.drugabuse.gov/aggregate/drug-facts/how-do-they-affect-brain

College Life

• Transitioning to college is very difficult for many students
• Some students do very well in high school but start out college very poorly
• College is dramatically different from high school in many ways

Career Ambivalence

• Lack of career goals and uncertainty about the future can lead to trouble with focus
• Without a defined career in mind, it will be hard to prioritize information
• It may be difficult to feel rewarded after hard work
• It may be hard to motivate yourself to make behavioral changes that will improve focus

Increased Career Self-Efficacy Predicts College Students’Motivation, and Course and Major Satisfaction. Komorraju et al. 2014.

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.891.3222&rep=rep1&type=pdf

Poor Study Skills

• Trying to study in a distracting place such as in your residence hall or apartment
• Using inefficient reading strategies such as trying to read a textbook cover to cover
• Not using techniques designed to help memory will lead to forgetting things
• Using technology (i.e. cell phones and computers) in a way that hurts instead of helps
• Sitting in the back of class

Anxiety Disorders

Anxiety

• Anxiety disorders are common among college students
• Anxiety disorders include generalized anxiety disorder, panic disorder, social anxiety disorder, and others
• Normal anxiety helps to motivate you to get work done
• Pathological anxiety interferes with your functioning (i.e. focusing)

https://www.apa.org/monitor/2013/06/college-students

Depression

• Depression is a condition where students feel sad most of the day for weeks at a time
• When students are depressed they often struggle with motivation and focus
• When mood improves so does ability to focus

Obsessive-Compulsive

Disorder

Obsessive- Compulsive

Disorder

• Obsessive-compulsive disorder (OCD) consists of obsessive thoughts and rituals
• The obsessive thoughts can be very distracting and make it hard to focus
• Rituals may include certain study rituals or perfectionistic habits that make it difficult to complete tasks

Trauma

• Trauma can be caused by ongoing emotional, physical, or sexual abuse
• It can also be caused by a life threatening experience such as a car accident
• Victims of trauma may meet criteria for Post-Traumatic Stress Disorder (PTSD)
• Students affected by trauma may have intrusive thoughts, avoidance, nightmares, and/or flashbacks

Medical Problems

• Many medical problems can affect our ability to focus
• These include acute illness such as influenza or a headache
• These can include chronic illness such as thyroid problems or diabetes
• It may be good idea to get routine labwork if you are having trouble focusing and think a medical issue may be involved
• It is important to manage chronic illnesses such as diabetes or thyroid problems effectively to minimize the impact on the brain

ADD or ADHD???

Symptoms of Inattention

• Trouble paying attention in class
• Making careless mistakes
• Difficulty organizing tasks
• Often losing things
• Easily distracted by extraneous stimuli
• Forgetful in daily activities

• Symptoms need to be everyday, worse than average student, and cause impairment
• Need to rule out other causes of inattention symptoms

Ruling out other Causes

Ruling out other Causes

While the internet can be helpful to find out about medical issues there is a lot of overlap between symptoms and diagnoses can get confused

How is ADHD Diagnosed?

ADHD Treatment

Healthy Lifestyle

• Lifestyle habits are things we do every day or almost every day that can make a big difference in how we feel and how we function
• These habits can help our focus or interfere with our focus
• College life sometimes encourages unhealthy lifestyle habits that interfere with our focus
• This section will help you learn new healthy lifestyle habits that improve focus

Get off the Hamster Wheel!

• College life can be stressful and it can get easy to get stuck in the same daily patterns that aren't working well
• Changing patterns in daily living can seem really challenging at first
• It can take work and practice to change patterns
• The daily patterns in the section are all evidence-based to improve focus
• It may be easiest to pick a few changes at first and see if you can maintain them
• The patterns will become easier to maintain over time
• You will feel a sense of accomplishment instead of feeling stuck in the same patterns

Sleeping Habits

• College students are sleep deprived!
• College life often encourages poor sleeping habits (i.e. staying up late, sleeping in, taking naps, and pulling "all-nighters"
• Improving sleep hygiene involves changing to sleeping habits that help our ability to stay focused

Rules of Sleep Hygiene

• Go to sleep and get up at the same time each day (this includes weekends!!!)
• Don’t take daytime naps!!! Napping can reset your sleep schedule and make it impossible to fall asleep at night. Staying on campus in the library or an empty classroom during the daytime will help prevent napping.
• If you can’t fall asleep within 30 minutes, get out of bed!!! Do something boring until you feel sleepy. Never stay in bed more than 1 hour without sleeping!
• Avoid caffeine in the afternoon or evening
• Use your bed only for sleeping
• Use white noise such as a fan to drown out noisy roommates

Why should I Change my Sleep Habits?

• "I like to do my work at night because it is quiet"
• "Most fun things happen at night"
• "Everyone else is sleeping in"
• "Everyone takes naps"
• "I don't have time to sleep"

• You may identify with the above quotes and be resistant to changing your sleep habits
• However, you wouldn't be doing the F.O.C.U.S. intervention if what you are doing is working for you
• What "everyone else is doing" contributes to a college environment that makes it very difficult to focus
• You may need to make a change if you want to be able to focus better

Healthy Eating

• The best diet for long term focus involves frequent meals rich in nutrients (vitamins, fats, and protein)
• These foods include fruits and vegetables, nuts, fish, and eggs
• Vegetarians and vegans may need to eat foods fortified in vitamins such as B12
• Eating frequent meals rich in these nutrients helps avoid hypoglycemia
• Avoid eating too much in one sitting to prevent fatigue and sleepiness
• Consider saving dessert until nighttime to act as a reward after hard work during the day
• Avoiding "empty calories" such as soda avoids weight gain and sugar crashes

Planning Meals

• "The are no healthy options on campus"
• "I am just too busy to eat healthy"
• "I want to stop eating junk food but its everywhere"

• You may identify with the quotes above
• If you struggle with eating habits, scheduling meal times might be helpful
• Prepare your healthy meals and snacks on days when your schedule is lightest so you have food ready when you are busy
• Get in the habit of taking your snacks and meals to campus with you during the day
• If you have a meal plan, SOVI dining hall offers numerous healthy options
• Healthy eating is important, work to make it a priority in your daily life

Exercise

• Over the course of a week, it is recommended that an adult get 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity, or a combination of moderate and vigorous activity
• Starting an exercise program is hard but well worth the benefit
• Most people require accountability to stick to an exercise regimen
• "Exercise is Medicine" is a great free program at FGCU to help with getting started and maintaining an exercise regimen

https://www.fgcu.edu/studentlife/campusrec/fitness/certificationsandevents

• Other ways to increase accountability include getting a personal trainer, exercising with a friend, or taking an exercise class

How will Exercise Help me Focus???

• Behavioral change starts with small steps
• You might be surprised how is easy it is to start exercising once you put on your workout gear
• You might be surprised how easy it is to eat healthy when you bring a healthy meal with you to campus

What to Drink?

• It is suggested that students should drink eight 8-ounce glasses of water per day
• Overhydration can occur, so pay attention to your body's thirst signal
• Drinking sugary drinks such as sodas cause "sugar crashes" and contribute to gaps in focus
• Drinking energy drinks are particularly prone to crashes because of the combination of sugar and caffeine
• Drinking sugary drinks increases weight gain and puts you at risk for diabetes

Caffeine

• Caffeine can improve focus but has side effects
• It is best to try other methods first (nutrition, sleep hygiene, etc...)
• If you feel you need caffeine, then limit usage to while in class or during a study block
• Timing is important as you will most likely experience a crash 4-6 hours later
• Have at least 2-3 days per week off caffeine to prevent tolerance and dependence
• It is wise to avoid all stimulants if you are feeling anxious

Prescription Stimulants

• It is best to not use prescription stimulants if they are not prescribed by a physician
• If you are prescribed stimulants it is important to take them correctly
• Take them with food to make sure you are not skipping meals
• Use good time management skills to make sure your are taking them during the daytime
• Stay hydrated

Alcohol

• It is best to avoid alcohol use if you struggle with focus
• However, binge drinking is very common among college students
• If you engage in drinking, try to remember that drinking large amounts of alcohol will cause a hangover and affect your focus the next day
• Hangover effects from alcohol may interfere with accurate ADHD testing

Marijuana

• It is best to avoid marijuana completely if you are struggling with focus
• If you are unwilling to give it up completely, at least try to limit usage to nights or weekends
• Remember that marijuana impacts memory formation
• Long term marijuana use can affect your motivation
• Having marijuana in your system or going through marijuana withdrawal may interfere with accurate ADHD testing

Other Drugs

• If you struggle with focus it is best to avoid using prescription drugs without a prescription (i.e. Xanax) and/or illegal drugs (i.e. cocaine)
• These drugs can be very addictive
• If you have developed an addiction to a drug it is a best to get help
• Talk to your counselor if you need help for substance use and/or addiction

Other

Drugs

Addiction Treatment

• Abstinence is the only effective treatment for addiction
• Get help from others (friends, counselors, and support groups)
• Change your environment
• Get rid of triggers (people, places, and things)
• This may involve changing your friend system and moving to a new place
• For addictive behaviors this may involve getting rid of the video game system, blocking internet access, etc…

Addiction

Balancing Demands

Learning to Use Time Effectively

• In order to balance demands it is important to use time effectively
• The next topics will focus on techniques that help you make better use of your time
• These topics include understanding procrastination, improving time management, using technology effectively, and improving study skills
• Implementing these techniques will help you be more aware of your time during the day and make more efficient use of it

Low Energy

• "Feeling lazy" and identifying as a "lazy person" are negative ways to describe low energy and doesn't get at causes
• When we feel in a state of low energy we often don't like doing work and put it off for later
• Feeling low energy can be caused by poor sleep, many medical conditions, substance misuse, lack of exercise, and poor nutrition
• Energy levels tend to fluctuate during the day and after eating

Anxiety

Poor Study Skills

Career Indecision

Feeding off Adrenaline

Time Management

• Block scheduling is a technique that has been well studied in college students to overcome procrastination and increase focus
• It involves blocking off time during the day (usually between and after classes) to study
• This weekly plan is usually created on Sundays before the upcoming week
• This can be done with a paper planner (one is available for printing after the F.O.C.U.S. quiz) or a digital system such as an app or phone calendar

Treating College like a Job

• Plan to take all your study materials with you in your backpack
• Make use of time in between classes and prevent “wasted” time
• Stay on campus during the day (DO NOT STOP AT HOME UNTIL YOU ARE DONE WITH ALL WORK!!!)
• You may need to bring your meals so you don't need to go back home
• Separate your work environment (classroom or library) from home environment (apartment or residence hall)
• Tell your friends you are not available for social time during the day
• Plan some time to reward yourself and relax after work is done for the day

Block Scheduling and Medication

• Plug your medication times into your block schedule to help you remember when to take it
• Use your cell phone calendar system with alarms to prevent forgetting medication and medical appointments
• Adhering to a block schedule is essential for students taking stimulants for ADHD (timing is very important with stimulants to prevent side effects such as missing meals or sleep interference)

Social Support

• When making behavioral changes it is very important to have social support
• Family and friends can provide encouragement and positive reinforcement
• They can help provide accountability to make sure you are sticking with the change
• Consider meeting a friend at the library during designated study times
• Encourage friends and family to help make sure you are getting up at the same time every day
• Consider getting academic coaching at the Center for Academic Achievement

Why Students May Resist Block Scheduling

• "I study best at home"
• "The library is too noisy for me"
• "I need lots of things going on to study"
• "My friends want to hang out during the day"
• "I have a job during the day"

• You may identify with these quotes from students
• However, you wouldn't be completing the F.O.C.U.S. Intervention if what you are doing currently is working
• You may need to make a change if you want to be able to focus better
• This may involve changing your class or job schedule to make it fit better with block scheduling techniques
• Students who make these changes often have increased GPA's (see link)

https://pdfs.semanticscholar.org/239e/551dffe83bb5377662ee7ca5a4e317462e5b.pdf

Technology

• Technology can be help us to stay focused and organized or can be very distracting
• Technology can include your cell phone, laptop, headphones, or other devices
• What are some ways technology can help?
• What are some ways technology distracts you?

Using to Technology to Help your Brain

• Plugging specific reminders in your cell phone calendar for appointments
• Consider having multiple alarms at different increments (24 hours, 1 hour, 15 minutes, etc...)
• Sync your Canvas calendar to your cell phone calendar to help keep track of upcoming deadlines
• Plugging your block schedule into your calendar to help remember your designated study times
• Plugging reminders in your calendar to remember daily routines such as taking medication or sleep and wake up times

How to Prevent Technology from Distracting your Brain

• If possible, leave the laptop or cell phone at home or off during study times
• If not possible, consider using apps such as "Freedom" that allow you to turn off certain apps and access to certain websites during specific periods of time
• Consider sending certain numbers directly to voicemail

Making the most out of the

Classroom

Reading

Textbooks Efficiently

Memorizing Material

Center for Academic Achievement

Being in the Moment

• When driving a car have you ever felt like you have driven for miles on automatic pilot without really being aware of what you are doing?
• In the same way, we may not be really present, moment-by-moment, for much of our lives
• Mindfulness is the basic human ability to be fully present, aware of where we are and what we’re doing, and not overly reactive or overwhelmed by what’s going on around us

What is

Mindfulness Meditation?

• Informal meditation is when you focus your mind to which ever activity you are doing during your day. This could include: brushing your teeth, cooking, cleaning, etc.
• Formal meditation is when you take time out of your day to practice meditation
• There is evidence that meditation can rewire the brain to make it less susceptible to stress and improve cognition and memory

Informal Meditations---Examples

• Getting out of bed
• When you first stand, take a deep breath in and stretch your hands as high as you can toward the ceiling, fingers pointing straight up. Then as you breathe out, relax, lean forward, and try to touch your toes. Make sure to focus on your breathing and the sensations of the stretch.

• Taking off your shoes
• We all like to take our shoes off after a long day. Pay attention to how your feet feel on the ground, try to move your toes around and feel each one individually.

Formal Meditation

• Find a distraction free area (especially important for beginners)
• Sit on a straight-backed chair or cross-legged on the floor
• Focus on an aspect of your breathing, such as the sensations of air flowing into your nostrils and out of your mouth, or your belly rising and falling as you inhale and exhale
• You will notice over time that you get better at dealing with distractions

Improving Focus

• Theoretical and experimental research suggests that mindfulness meditation is associated with changes in neural pathways and may be particularly effective in promoting improved focus
• The goal of mindfulness is not perfection but instead steadily improving the four facets of attention

Four Main Facets of Attention

• Mind Wandering
• Thoughts beginning to stray
• Distraction awareness
• The ability to recognize if/when your attention wanders
• Reorientation of awareness
• The ability to disengage from a distraction and refocus as necessary
• Sustaining focus
• Degree to which you sustain your focus on that particular object, despite distractions

Mindfulness Techniques to Improve Focus

• The Mental Focus Exercise:
• Place an object in front of you and start focusing on it
• Stare at the object as long as you can
• Keep a check on when your mind begins to wander, acknowledge the thoughts which it brings and then lovingly bring it to the object with which you were focusing on
• Often, engaging with the object can help increase the duration of your focus
• The longer you are able to focus on the object, the more your mindfulness will increase
• This, in turn, will enhance your focusing abilities

Reorientation of Awareness

• Mindful Pausing
• A technique to bring your attention back into the present moment in the midst of daily experience
• Focus on taking a single full breath
• Observe (notice if you lose focus on that single full breath)
• Refocus if needed

Grounding

• This is a useful technique when we are having trouble staying 'in the present'
• Use your senses to guide your awareness
• Name 5 things you see in this moment (describe them)
• Name 4 things you hear in this moment (describe them)
• Name 3 things you are touching or are touching you
• Name 2 things you smell
• Name 1 thing you taste

Mindfulness Techniques for Anxiety

• Anchoring
• One of the best ways to calm yourself down is to anchor yourself by directing your attention into the lower half of your body
• Begin by focusing on your feet and how they feel inside your socks or shoes and against the ground
• Expand your attention to include the sensations first in your lower legs and then in your upper legs – do they feel heavy or light? Warm or cool? Tingly or numb?
• Now include the sensations of your breathing, really relaxing as you breathe out

Breath Counting

• On your next in-breath, count up to 6 as you breathe all the way in, and then on the out-breath, count up to 10 as you breathe all the way out (only do this for one breath)
• This technique has the effect of slowing down your breathing
• It also lengthens the out-breath more than the in-breath, forcing you to release more carbon dioxide
• This slows your heart rate, calming you down, and restores emotional equilibrium

Finger Breathing

• Hold one hand in front of you, palm facing towards you.
• With the index finger of your other hand, trace up the outside length of your thumb while you breath in, pausing at the top of your thumb and then trace it down the other side while you breath out. That’s one breath.
• Trace up the side of the next finger while you breathe in, pause at the top, and then trace down the other side of that finger while you breathe out. That’s two breaths.
• Keep going, tracing along each finger as you count each breath. When you get the end of the last finger, come back up that finger and do it in reverse

F.O.C.U.S. Quiz

• Congratulations! You have reached the end of the presentation
• Remember, behavioral changes take practice to implement
• Many patterns in life such as sleeping habits, substance use, and eating habits have existed for a long time and aren't often changed overnight
• Mindfulness exercises also need to be practiced regularly
• By using mindfulness regularly you can train your brain to focus better
• After reviewing the F.O.C.U.S. Prezi (for at least an hour) please complete the F.O.C.U.S Quiz to test your knowledge

https://survey.fgcu.edu/surveys/quiz_scoring.aspx