by Edward M. Hallowell, M.D. and John J. Ratey, M.D.
The treatment of adult ADHD begins with hope. Most people who discover they have ADHD, whether they be children or adults, have suffered a great deal of pain. The emotional experience of ADHD is filled with embarrassment, humiliation, and self-castigation. By the time the diagnosis is made, many adults with ADHD have lost confidence in themselves. Many have consulted with numerous specialists, only to find no real help. As a result, many have lost hope.
The most important step at the beginning of treatment is to instill hope once again. Individuals with ADHD may have forgotten what is good about themselves. They may have lost, long ago, any sense of the possibility of things working out. They are often locked in a kind of tenacious holding pattern, bringing all theory, considerable resiliency, and ingenuity just to keeping their heads above water. It is a tragic loss, the giving up on life too soon. But many adults with ADHD have seen no other way than repeated failures. To hope, for them, is only to risk getting knocked down once more.
And yet, their capacity to hope and to dream is immense. More than most people, adults with ADHD have visionary imaginations. They think big thoughts and dream big dreams. They can take the smallest opportunity and imagine turning it into a major break. They can take a chance encounter and turn it into a grand evening out. They thrive on dreams, and they need organizing methods to make sense of things and keep them on track.
But like most dreamers, they go limp when the dream collapses. Usually, by the time the diagnosis of ADHD has been made, this collapse has happened often enough to leave them wary of hoping again. The little child would rather stay silent than risk being taunted once again. The adult would rather keep his mouth shut than risk flubbing things up once more. The treatment, then, must begin with hope.
We break down the treatment of adult ADHD into five basic areas:
- Structure, support, and coaching
- Various forms of psychotherapy
In this pamphlet we will outline some general principles that apply both to children and adults concerning the non-medication aspects of the treatment of ADHD. One way to organize the non-medication treatment of ADHD is through practical suggestions or “tips” on management. Fifty such tips are presented below:
Insight and Education
- Be sure of the diagnosis. Make sure you’re working with a professional who really understands ADHD and has excluded related or similar conditions such as anxiety states, agitated depression, hyperthyroidism, manic-depressive illness, or obsessive-compulsive disorder.
- Educate yourself. Perhaps the single most powerful treatment for ADHD is understanding ADHD in the first place. Read books. Talk with professionals. Talk with other adults who have ADHD. You’ll be able to design your own treatment to fit your own version of ADHD.
- Coaching. It is useful for you to have a coach, for some person near you to keep after you, but always with humor. Your coach can help you get organized, stay on task, give you encouragement or remind you to get back to work. Friend, colleague, or therapist (it is possible, but risky for your coach to be your spouse), a coach is someone to stay on you to get things done, exhort you as coaches do, keep tabs on you, and in general be in your corner. A coach can be tremendously helpful in treating ADHD.
- Encouragement. ADHD adults need lots of encouragement. This is in part due to their having many self-doubts that have accumulated over the years. But it goes beyond that. More than the average person, the ADHD adult withers without encouragement and positively lights up like a Christmas tree when given it. They will often work for another person in a way they won’t work for themselves. This is not “bad”, it just is. It should be recognized and taken advantage of.
- Realize what H is NOT, i.e., conflict with mother, etc.
- Educate and involve others. Just as it is key for you to understand ADHD, it equally if not more important for those around you to understand it–family, job, school, friends. Once they get the concept they will be able to understand you much better and to help you as well.
- Give up guilt over high-stimulus-seeking behavior. Understand that you are drawn to high stimuli. Try to choose them wisely, rather than brooding over the “bad” ones.
- Listen to feedback from trusted others. Adults (and children, too) with ADHD are notoriously poor self-observers. They use a lot of what can appear to be denial.
- Consider joining or starting a support group. Much of the most useful information about ADHD has not yet found its way into books but remains stored in the minds of the people who have ADHD. In groups this information can come out. Plus, groups are really helpful in giving the kind of support that is so badly needed.
- Try to get rid of the negativity that may have infested your system if you have lived for years without knowing what you had was ADHD. A good psychotherapist may help in this regard.
- Don’t feel chained to conventional careers or conventional ways of coping. Give yourself permission to be yourself. Give up trying to be the person you always thought you should be–the model student or the organized executive, for example–and let yourself be who you are.
- Remember that what you have is a neuropsychiatric condition. It is genetically transmitted. It is caused by biology, by how your brain is wired. It is NOT a disease of the will, nor a moral failing. It is NOT caused by a weakness in character, nor by a failure to mature. It’s cure is not to be found in the power of the will, nor in punishment, nor in sacrifice, nor in pain. ALWAYS REMEMBER THIS. Try as they might, many people with ADHD have great trouble accepting the syndrome as being rooted in biology rather than weakness of character.
- Try to help others with ADHD. You’ll learn a lot about the condition in the process, as well as feel good to boot.
- External structure. Structure is the hallmark of the non-pharmacological treatment of the ADHD child. It can be equally useful with adults. Tedious to set up, once in place structure works like the walls of the bobsled slide, keeping the speedball sled from careening off the track.
- Make frequent use of:
- notes to self
- Color coding. Mentioned above, color-coding deserves emphasis. Many people with ADHD are visually oriented. Take advantage of this by making things memorable with color: files, memoranda, texts, schedules, etc. Virtually anything in the black and white of type can be made more memorable, arresting, and therefore attention-getting with color.
- Use pizzazz. In keeping with #15, try to make your environment as peppy as you want it to be without letting it boil over.
- Set up your environment to reward rather than deflate. To understand what a deflating environment is, all most adult ADHD’ers need do is think back to school. Now that you have the freedom of adulthood, try to set things up so that you will not constantly be reminded of your limitations.
- Acknowledge and anticipate the inevitable collapse of X% of projects undertaken, relationships entered into, obligations incurred.
- Embrace challenges. ADHD people thrive with many challenges. As long as you know they won’t all pan out, as long as you don’t get too perfectionistic and fussy, you’ll get a lot done and stay out of trouble.
- Make deadlines.
- Break down large tasks into small ones. Attach deadlines to the small parts. Then, like magic, the large task will get done. This is one of the simplest and most powerful of all structuring devices. Often a large task will feel overwhelming to the person with ADHD. The mere thought of trying to perform the task makes one turn away. On the other hand, if the large task is broken down into small parts, each component may feel quite manageable.
- Prioritize. Avoid procrastination. When things get busy, the adult ADHD person loses perspective: paying an unpaid parking ticket can feel as pressing as putting out the fire that just got started in the wastebasket. Prioritize. Take a deep breath. Put first things first. Procrastination is one of the hallmarks of adult ADHD. You have to really discipline yourself to watch out for it and avoid it.
- Accept fear of things going well. Accept edginess when things are too easy, when there’s no conflict. Don’t gum things up just to make them more stimulating.
- Notice how and where you work best: in a noisy room, on the train, wrapped in three blankets, listening to music, whatever. Children and adults with ADHD can do their best under rather odd conditions. Let yourself work under whatever conditions are best for you.
- Know that it is O.K. to do two things at once: carry on a conversation and knit, or take a shower and do your best thinking, or jog and plan a business meeting. Often people with ADHD need to be doing several things at once in order to get anything done at all.
- Do what you’re good at. Again, if it seems easy, that is O.K. There is no rule that says you can only do what you’re bad at.
- Leave time between engagements to gather your thoughts. Transitions are difficult for ADHD’ers, and mini-breaks can help ease the transition.
- Keep a notepad in your car, by your bed, and in your pocketbook or jacket. You never know when a good idea will hit you, or you’ll want to remember something else.
- Read with a pen in hand, not only for marginal notes or underlining, but for the inevitable cascade of “other” thoughts that will occur to you.
- Have structured “blow-out” time. Set aside some time in every week for just letting go. Whatever you like to do–blasting yourself with loud music, taking a trip to the race track, having a feast–pick some kind of activity from time to time where you can let loose in a safe way.
- Recharge your batteries. Related to #30, most adults with ADHD need, on a daily basis, some time to waste without feeling guilty about it. One guilt-free way to conceptualize it is to call it time to recharge your batteries. Take a nap, watch T.V., meditate. Something calm, restful, at ease.
- Choose “good”, helpful addictions such as exercise. Many adults with ADHD have an addictive or compulsive personality such that they are always hooked on something. Try to make this something positive.
- Understand mood changes and ways to manage these. Know that your moods will change willy-nilly, independent of what’s going on in the external world. Don’t waste your time ferreting out the reason why or looking for someone to blame. Focus rather on learning to tolerate a bad mood, knowing that it will pass, and learning strategies to make it pass sooner. Changing sets, i.e., getting involved with some new activity (preferably interactive) such as a conversation with a friend or a tennis game or reading a book will often help.
- Related to #34, recognize the following cycle which is very common among adults with ADHD: Something “startles” your psychological system, a change or transition, a disappointment or even a success. The precipitant may be quite trivial. This “startle” is followed by a mini-panic with a sudden loss of perspective, the world being set topsy-turvy. You try to deal with this panic by falling into a mode of obsessing and ruminating over one or another aspect of the situation. This can last for hours, days, even months.
- Plan scenarios to deal with the inevitable blahs. Have a list of friends to call. Have a few videos that always engross you and get your mind off things. Have ready access to exercise. Have a punching bag or pillow handy if there’s extra angry energy. Rehearse a few pep talks you can give yourself, like, “You’ve been here before. These are the ADHD blues. They will soon pass. You are O.K.”
- Expect depression after success. People with ADHD commonly complain of feeling depressed, paradoxically, after a big success. This is because the high stimulus of the chase or the challenge or the preparation is over. The deed is done. Win or lose, the adult with ADHD misses the conflict, the high stimulus, and feels depressed.
- Learn symbols, slogans, sayings as shorthand ways of labelling and quickly putting into perspectives slip-ups, mistakes, or mood swings. When you turn left instead of right and take your family on a 20-minute detour, it is better to be able to say, “There goes my ADHD again,” than to have a 6-hour fight over your unconscious desire to sabotage the whole trip. These are not excuses. You still have to take responsibility for your actions. It is just good to know where your actions are coming from and where they’re not.
- Use “time-outs” as with children. When you are upset or overstimulated, take a time-out. Go away. Calm down.
- Learn how to advocate for yourself. Adults with ADHD are so used to being criticized, they are often unnecessarily defensive in putting their own case forward. Learn to get off the defensive.
- Avoid premature closure of a project, a conflict, a deal, or a conversation. Don’t “cut to the chase” too soon, even though you’re itching to.
- Try to let the successful moment last and be remembered, become sustaining over time. You’ll have to consciously and deliberately train yourself to do this because you’ll just as soon forget.
- Remember that ADHD usually includes a tendency to overfocus or hyperfocus at times. This hyperfocusing can be used constructively or destructively. Be aware of its destructive use: a tendency to obsess or ruminate over some imagined problem without being able to let it go.
- Exercise vigorously and regularly. You should schedule this into your life and stick with it. Exercise is positively one of the best treatments for ADHD. It helps work off excess energy and aggression in a positive way, it allows for noise-reduction within the mind, it stimulates the hormonal and neurochemical system in a most therapeutic way, and it soothes and calms the body. When you add all that to the well-known health benefits of exercise, you can see how important exercise is. Make it something fun so you can stick with it over the long haul, i.e., the rest of your life.
- Make a good choice in a significant other. Obviously this is good advice for anyone. But it is striking how the adult with ADHD can thrive or flounder depending on the choice of mate.
- Learn to joke with yourself and others about your various symptoms, from forgetfulness, to getting lost all the time, to being tactless or impulsive, whatever. If you can be relaxed about it all to have a sense of humor, others will forgive you much more.
- Schedule activities with friends. Adhere to these schedules faithfully. It is crucial for you to keep connected to other people.
- Find and join groups where you are liked, appreciated, understood, enjoyed. Conversely, don’t stay too long where you aren’t understood or appreciated.
- Pay compliments. Notice other people. In general, get social training, as from your coach.
- Set social deadlines.
Edward (Ned) Hallowell is a child and adult psychiatrist and the founder of The Hallowell Center for Cognitive and Emotional Health in Sudbury and Andover, MA. His groundbreaking books, including Driven to Distraction, a 1994 bestseller about attention-deficit disorder, and Worry, about how to control anxiety, have distinguished him as one of the country’s leading psychiatrists. Visit his website at drhallowell.com.
John J. Ratey, M.D., is an Associate Professor of Psychiatry at Harvard Medical School, and has a private practice in Cambridge, Massachusetts. He has lectured and published many articles on the topic of treating ADHD (attention deficit disorder) in adults using psychoeducation and pharmacotherapy. He specifically is interested in the impact of ADHD on life issues such as relationships, employment, and personal fulfillment. His website is www.johnratey.net.
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