Living with Attention Deficit Hyperactivity Disorder
If you’re a parent of a child who’s recently been diagnosed with attention deficit hyperactivity disorder (ADHD), you may be devastated and overwhelmed. If you’re an adult who’s recently been diagnosed, you may be going through “various stages of grief” after learning that your “lifelong difficulties can now be explained by a medical condition,” said Terry Matlen, MSW, ACSW, licensed psychotherapist and founder of ADD Consults. Fortunately, ADHD is highly treatable and whether one is diagnosed at 30 or 80, “your quality of life will change for the better,” Matlen said.
But knowing what treatments are effective and how to find them can seem just as overwhelming as the diagnosis. Here’s a clear-cut look at managing ADHD, from evaluation to treatment.
- ADHD is over-diagnosed. “It really depends on the community; ADHD can be over-diagnosed in some communities and under-diagnosed in others,” said Arthur L. Robin, Ph.D, licensed psychologist and chief of psychology at the Children’s Hospital of Michigan. For instance, ADHD may be under-diagnosed in an inner city where no one talks about it, but over-diagnosed in an affluent suburban area, where parents are more aware of ADHD and may think their child has the condition if he or she isn’t doing well in school.
- Inattention, distractibility and impulsivity are character flaws. ADHD is a neurobiological disorder, and these “character flaws” are symptoms.
- You can will yourself out of ADHD. “The fact is, and research backs this, that the harder one tries, the worse the symptoms seem to get,” Matlen said.
- Children outgrow ADHD. “What people typically outgrow is the hyperactive part of ADHD. What remains is the inattentive and impulsive parts of the disorder which can cause impairments in academic, personal and occupational arenas,” said Adelaide Robb, M.D., associate professor of psychiatry and pediatrics at the Children’s National Medical Center in Washington, DC.
“The best antidote to under-diagnosis and over-diagnosis is an appropriate evaluation,” Robin said. Pediatricians, who are at the frontline, don’t have the time necessary to conduct a comprehensive evaluation, so they may jump to conclusions and prescribe medication, he said. To avoid this, ask your pediatrician to help you find a mental health professional. Also, note that ADHD symptoms must occur across settings, including at school and home. Adults can ask their primary care physicians for a referral.
According to Robin, an appropriate evaluation entails: systematically reviewing ADHD symptoms from the DSM-IV with parents; getting input from teachers, who complete standardized rating scales; conducting a thorough interview with parents and children; and ruling out alternative explanations. To rule out learning disabilities or low cognitive ability, the practitioner administers an IQ and achievement test.
For diagnosis in adults see here.
Steps to Successful Treatment
- “Be thankful. ADHD is a condition that can be managed effectively when it is recognized and understood,” said Peter Jaksa, clinical psychologist and director of ADHD Centers in Chicago.
- Educate yourself about ADHD. Whether it’s you or your child, become an authority on ADHD. Read online resources (e.g., Psych Central, Attention Deficit Disorder Association, Children and Adults with Attention Deficit/Hyperactivity Disorder); attend conferences ; and seek support groups.
For parents, learn about how ADHD affects your child “in school, socially and at home”; what parenting techniques work for kids with ADHD; and your child’s educational rights, Matlen said. For adults, understand your ADHD brain by cataloguing how ADHD impacts your daily functioning, Robin said. For some, the biggest impact is on organization, ability to follow through, short-term memory and attention to details, he said. Does ADHD interfere with work, intimate relationships, parenting your kids?
- Talk to professionals about treatment options. Choose professionals who regularly see people with ADHD. Look at your treatment options as “tools in a tool chest to be used as needed across your life,” Robin said. These tools typically include medication, cognitive-behavioral therapy (CBT) and organizational strategies—an effective combination for treating ADHD.
- Become an advocate. “Parents are the most important and strongest advocates” for their kids, Jaksa said. Help kids “understand that they aren’t ‘dumb’—that their brains are simply wired differently,” Matlen said. “Meet with your child’s teachers before school starts to inform them about your child’s history and “discuss strategies that would be helpful for your child,” Jaksa said. If your child doesn’t have an Individualized Education Plan (IEP), talk to the principal and school psychologist about doing the evaluation, he said. Don’t be afraid to ask how therapy is going, Robin said. If it doesn’t seem successful, seek another therapist.
Disclosing Your Diagnosis
“People with ADHD should treat their personal ADHD information like any other kind — think about who should know and what that information could do, both in a positive or potentially negative way,” Matlen said. Telling loved ones may help them better understand what’s been going on and allow them to be helpful and supportive, she said. If loved ones don’t seem to understand, “give them articles, books and websites where they can learn more,” Matlen said.
At work, Sandy Maynard, M.S., an ADHD coach who operates Catalyst Coaching, advises against disclosing your diagnosis. Instead, identify “what you need to perform better” and ask for it, she said. A boss will rarely refuse a reasonable accommodation.
ADHD “is a lifelong condition that doesn’t go away, so managing it is a lifelong responsibility”; however, this doesn’t mean that individuals will need medication or therapy forever, Jaksa said. “There are millions of people with ADHD living productive, happy lives who have learned how to manage it well and no longer need professional treatment, or only need treatment for a brief time to deal with challenging life changes,” he said.
Traditional talk therapies that focus on insight and support are ineffective for ADHD. The best approach is for therapists to use evidence-based manuals, which research has shown are effective—like CBT—and adapt them to individual cases, Robin said. “The therapy needs to be more behavioral, practical and goal directed,” Jaksa said.
CBT targets maladaptive thoughts and behaviors. A therapist helps individuals move from “I can never be successful” to “I may have failed at some things, but I can make changes.” When procrastination is a problem, a therapist will help “develop prompts, reminders, schedules, time management tools to accomplish major tasks,” Robin said.
You’ll work on prioritizing, problem solving and picking the best solution, said Steven A Safren, Ph.D., director of behavioral medicine at Harvard Medical School and co-author of Mastering Your Adult ADHD. “We try to make people know what they need to do. If they decide not to do it that’s a rational decision, vs. a surprise of backed-up bills, taxes and homework,” he said. Therapy also may address low self-esteem, anxiety and depression, as these commonly co-occur with ADHD.
The length of therapy depends on the type of patient and the presence of co-occurring conditions, which can prolong treatment. Adults seeking therapy to improve organization, time management and defeating thoughts can see improvement in 10 to 12 sessions with CBT, Robin said. Sessions are once a week or every other week. With younger patients, therapists mainly work with parents on management strategies. Modifying behavior and improving school functioning typically takes about 10 to 15 sessions over four to six months, he said. For teens, 18 sessions is recommended, which Robin and his colleagues outline in the manual, Defiant Teens.
Learn more about childhood treatment here.
Common Challenges in Psychotherapy
- Teens. Adolescents usually don’t want to attend therapy, said Robin, co-author of Your Defiant Teen: 10 Steps to Resolve Conflict and Rebuild Your Relationship. They may be in denial about their diagnosis and refuse to deal with it. Instead of being confrontational, Robin finds what the teen is passionate about (e.g., sports) and discusses how ADHD may improve that interest.
- Appointments. Patients commonly forget their therapy appointments. This is why it’s important to start treatment by creating a calendar system—it facilitates therapy—which Safren’s CBT model does.
- Tasks. Individuals have difficulty completing tasks between sessions, because they simply forget. Some of Robin’s patients “take brief notes during the therapy session and clearly summarize the action steps to take before the session,” he said.
- Relationships. Patients’ significant others may misconstrue their behavior and believe the patient isn’t motivated to change, not realizing that ADHD is to blame, Robin said. Bringing your significant other to therapy can help tremendously.
Pharmacological therapy usually follows these steps:
- Selecting a medication. “Many adults will benefit from the same medications as benefit kids with ADHD,” Robin said. “Selecting medication includes gathering information about other blood relatives with the same disorder who responded well or poorly to a specific condition,” said Dr. Robb, the psychiatrist at Children’s National Medical Center.
When patients take their medication depends on how ADHD impairs them, Robin said. Work with your physician to identify the purpose of your medication. Children typically take medication to improve school performance, social interactions and impulsive behavior, he said. Some of the adults Robin works with are mostly concerned about positive interactions and “not losing their cool with their spouses and kids.” They take medication in the evenings and weekends. Other adults have difficulty focusing on work, so they take medication during the day.
- Starting medication. The doctor prescribes medication at its lowest dose to minimize side effects “titrated up to a target and or maximum dose until ADHD symptoms improve or side effects become troublesome,” Dr. Robb said.
- Seeing improvement. Two-thirds of individuals starting on a stimulant will experience a “good result” with the first medication, she said. You’ll typically notice an improvement in attention and concentration and reductions in hyperactivity, physical restlessness, impulsivity and “activation difficulties”—easier-to-start tasks patients usually avoid, Jaksa said. Of individuals starting Strattera, three-fifths will have a good result, Dr. Robb said.
For information on medication in children, check out this parent-friendly guide.
Concerns about Medication
People have various concerns about medication, including worries that it leads to dependence and substance abuse, can stunt growth and increase the risk for suicide and cardiovascular problems.
“If the person is taking the right medication, at the right dosage level for him or her, the side effects of stimulants tend to be pretty mild – some appetite loss, maybe trouble falling asleep, some increase in blood pressure for some individuals,” Jaksa said.
According to research and clinical experience, when stimulant medication is taken properly, it isn’t physically addictive, he said. In fact, “People with ADHD who are properly medicated have less substance abuse, and less risk for future abuse, than those who are not medicated,” Jaksa said. He added that ADHD medications will not stunt a child’s growth as long as the child is receiving proper nutrition.
If patients are taking medications that increase the risk for suicide, they “should be monitored for those thoughts,” Dr. Robb said. Before medication is started, the physician should obtain a familial history of “cardiovascular risks, including fainting episodes and change in exercise tolerance,” she said. If taking stimulants, adults with heart disease or high blood pressure “should be followed closely by their cardiologist/internist.”
Tips for taking medication safely and effectively include:
- Take it consistently.
- Never adjust the dose without medical supervision.
- Communicate with your doctor.
- Disclose if you’re taking any “vitamin/herbal supplements, over-the-counter medications and prescription medications, and if you’ve developed a new medical condition (e.g., asthma),” Dr. Robb said.
- Make medication part of your daily routine (e.g., take it after breakfast), Jaksa said. Use reminders: Carry a pill box, set the alarm on your watch or have backup medication at school or work, Safren said.
- Avoid alcohol and illicit drugs.
An ADHD coach also can become an integral part of your treatment team. A coach provides individuals with strategies and tools to accomplish their goals and overcome challenges. “A coach can be there in the moment,” Robin said. One of the coaches Robin collaborates with holds weekly homework sessions to help teens complete schoolwork effectively.
When choosing a qualified coach, get professional testimonials (from psychologists or psychiatrists) and ask about educational background. Look for a relevant degree such as psychology or education, which serves as a foundation for coaching. Ask about conferences the coach attends and how many ADHD clients he or she sees, said Maynard, who was instrumental in developing The National Attention Deficit Disorder Association’s coaching guidelines.
For more information on coaching and how it differs from therapy, see here.
Pitfalls and Pointers
Everyone is bound to make mistakes when managing ADHD or parenting a child with ADHD. Here’s a list of common pitfalls followed by practical solutions:
- Slacking off on organizational and time management tools, leading to “a slow downward spiral,” Maynard said.
Fix this by using the system until it becomes automatic, Safren said. As a reminder, create a list of current goals and email them to yourself at random times, as one of Maynard’s clients does.
- Snapping at a loved one or colleague; being passive-aggressive.
For starters, make sure you’re getting enough sleep, nutrition and exercise, all of which help our moods, Maynard said. For instance, exhaustion can exacerbate anger.
Identify your triggers and intervene, she said. Try relaxing your shoulders, counting to 10 or taking deep breaths. Instead of talking “in the heat of the moment,” say “I need a time out,” Robin said. Instead of shooting off an email, put it in your draft folder and read it when you’ve calmed down, Maynard said.
- Forgetting things, especially when leaving the house.
Before flying out the door, “pat down” (Do I have my keys, cell phone, wallet and planner?), “look around” (“what have I left behind? Is the oven off?”) and “think about” (“what was I just doing?” and “what am I doing next?”), Maynard said. Apply this to work: After a meeting, immediately review your calendar and consider what you need to do next.
- Trying to reason with children age 10 or younger.
Apply positive and negative consequences, Robin said. For more information on behavioral strategies, see here.
- Grounding a child for bad grades.
This doesn’t improve a child’s school performance. Instead, create consequences that will do so, such as “do 20 minutes of extra math problems every day,” Robin said.
- Doing just one more thing before you leave.
Set a schedule at the beginning of the day, and train yourself to stick to it no matter what, Robin said.
- Hopping from one paper topic to the fifth.
Though you may know more about these subjects than the professor, you still receive an F, because you never submitted the assignment. Define the objective of your project; break it down into definable pieces and ask the professor for suggestions on approaching the project, Maynard said. At work, consult your colleagues or boss about how to approach the project.
- Get enough sleep. “ADHD symptoms worsen with lack of sleep,” Matlen said. Stay away from stimulating activities (such as computer games or TV) at least one hour before bed, find boring things to help slow down the brain and write down thoughts and plans to reduce ruminating in bed, she said. Keep a regular sleep schedule.
- Get regular exercise. This is dismissed as just another common piece of advice, but “studies show that exercise does help with cognition, memory, hyperactivity and more,” Matlen said.
- Get help. Whether it’s hiring a professional organizer, ADD coach or babysitter—even when you’re at home—“allow yourself to get help,” said Matlen, author of Survival Tips for Women with ADHD.
- Re-evaluate expectations. Societal expectations for women are endless, from the perfect mom to the flawless homemaker. “As Dr. Ned Hallowell says, ‘just be organized enough,’ meaning don’t beat yourself up if you can’t keep your house immaculate. Just keep things organized enough so you can get by,” said Matlen, who also co-hosts a website for women with ADHD.
- Boost self-confidence. ADHD can shatter self-esteem. To cultivate confidence, Maynard suggested: Stay focused on accomplishments, not shortfalls; don’t compare yourself to others; pat yourself on the back when others don’t; view mistakes as learning experiences; and choose friends wisely, avoiding overly critical or judgmental people.
- Make tasks meaningful. To complete tasks, individuals usually need to be excited and engaged. “Find a way to make that task meaningful for you to stay motivated and follow through,” Maynard said.
- Show up. If you’re unable to focus, your first instinct is to skip class. Instead, “suit up and show up, because you will walk away with something and learn,” Maynard said.
- Study smarter. When studying, “know yourself,” she said. Ask yourself: “How do I study best — in my dorm or the library; with a partner or alone; early in the morning or in the afternoon?”
- Avoid multitasking and discard distractions. Before starting a project, identify things that disrupt your concentration, Maynard said. It also may help to quantify your attention span. Time how long you pay attention to a task, and then try working on the task for that long, Safren said.
- Prepare for the worst. Though you can’t plan for everything, think about your worst-case scenario and how you can prevent it, Maynard said. For instance, you may keep your calendar on your computer and cell phone and own a hard copy.
Tartakovsky, M. (2013). Living with Attention Deficit Hyperactivity Disorder. Psych Central. Retrieved on August 1, 2015, from http://psychcentral.com/lib/living-with-attention-deficit-hyperactivity-disorder/