Managing Treatment

Secrets of ADHD Treatment

You have ADHD — so your treatment plan should be based on how people with attention deficit think, feel, and live.

ADHD Woman sitting on bench with back turned looking at the park thinking
ADHD Woman sitting on bench with back turned looking at the park thinking

Life is hard for a person with an ADHD-style nervous system. He is over-aroused and disorganized most of the time, yet he has to live with and enjoy neurotypical people in a neurotypical world. It is hard work, and it is best started early, before bad habits and low self-esteem set in.

During his early years of development, no child, whether he has ADHD or not, has the ability or insight to participate in the therapeutic process. We should not wait, though, to step in and assist children who have ADHD. The earlier we recognize that they have the condition, and respond accordingly, the better for everyone.

The treatment tools that work for an ADHD-style nervous system are comparatively easy to acquire. It is hard, though, to undo the years of harsh and unhelpful feedback to which a person with ADHD has been exposed. It is equally hard to undo adjustments and habits that a person has built up over a lifetime to compensate for a nervous system that plays by different rules.

So here is a treatment plan based on how people with ADHD think, feel, and live. One caution: ADHD treatment is at high risk to fail unless a trusted significant other is involved — and stays involved — from the beginning. For at least the first year, the motivation for treatment and the ability to see the benefits will reside primarily in someone other than the patient.

Be True to Yourself

I have been amazed that some people with ADHD and co-existing conditions grow up to be fully functioning adults. They are successful in their jobs and have strong relationships. They raise healthy, resilient children (half of whom also have ADHD-style nervous systems). What is it about them and their upbringing that helped them become happy, loving adults?

The most important factor is someone who unshakably believes that the child or adult with ADHD is a good person. A young child needs someone to tell her that she is hardworking, intelligent, and loving: a parent, brother or sister, a grandparent, neighbor, or a teacher. This cheerleader distinguishes between the child’s worth and her achievements — to say, “I know you. I know that if anyone could have been successful through hard work and perseverance, you would have been. Something we haven’t yet identified must be getting in your way. I want you to know that I will stick with you until we figure out what is getting in your way and fix it.”

Since most parents and spouses do not understand how the ADHD brain is wired, they try what worked for them as kids, or say what their parents told them when they failed or fell short. The most common response is to admonish the child and insist that he re-try the techniques that just failed him. The implication is that the child did something wrong or did not apply the technique hard enough or long enough. Either way, it is the child who is wrong, not the technique. This approach suggests that the child failed because he has a fundamental flaw. He has bad character (“You’re lazy”) or is consciously defying you (“You can do it if you really try”).

The parent or non-ADHD spouse has to ask, and honestly answer, the question: Do I really want my child or spouse to be neurotypical and do things the way I do them? Or do I want him to be the best person with ADHD he can be?

Know Thy ADHD

ADHD therapy must start with understanding what ADHD is, what is possible for the person to achieve, and what is not. Accountability and responsibility are good things, but only if they lead to success. Such judgment calls are among the most difficult that a parent, spouse, or loved one has to make. Sometimes it is not clear what is possible and what is not. What is not possible now may be possible later.

Do not hold people accountable for things that are impossible for them to accomplish. This has been the basis of many therapeutic methods that have never shown lasting benefits. Their only outcome is serial failure. The more the ADHD person loves the authority figure and wants to please him, the greater the pain and frustration of failure.

The person with ADHD should not be the sole focus of therapeutic intervention. It is important that everyone in the family knows what is going on and how to be part of the solution. It is also important to acknowledge the problems encountered by other children in the family. Most non-ADHD siblings spend their childhoods feeling shortchanged or neglected because they were good and didn’t require a lot of attention.

Level the Neurological Playing Field

The successful treatment of ADHD symptoms should include medication that is consistently taken. Several years ago, a group of practitioners argued about whether to require their clients to take medication before coming to therapy sessions. They talked with other ADHD practices and research clinics to see what they did. We concluded that our clients should be on medication when they came in for their sessions. If they weren’t, they were sent home and charged for the session. My advice to ADHD patients and their spouses is:

If you’ve tried ADHD counseling or coaching without ADHD medication and didn’t get the outcome you expected, try it again with medication.

If you tried medication and did not like how you felt on it, find a clinician with more experience treating ADHD and try again. Most patients eventually find the medication and the dose that work well without side effects or changes in personality.

For a child with ADHD who might also have learning disabilities, the American Academy of Child and Adolescent Psychiatry recommends that psycho-educational testing wait until ADHD medication has been optimized. Untreated ADHD may confuse the testing results.

If an individual with ADHD doesn’t believe in medication, and won’t try it long enough to see what it has to offer, he is insisting that things have to happen on his terms. Nothing will change for the better. Not ADHD or anything else. The recovery community embraces the acronym HOW. So should the ADHD community:

1. Honesty — admit the effect that ADHD has had on your life and on your loved ones

2. Openness — don’t hold anything back out of fear of being humiliated, blamed, or shamed

3. Willingness to do what it takes to take control of your life.

Medication can return the patient’s attention span, impulsivity, and motor movements to higher levels. With medication, most people with ADHD are on a level playing field, often for the first time in their lives.

Say Good-Bye to Non-ADHD Solutions

Pills do not give skills. If patients normalize their symptoms with medication, but continue to approach the tasks of life with neurotypical techniques that will never work for them, nothing changes. To develop confidence that they can access their abilities on demand is a two-step process.

First, they must finally and irrevocably abandon the notion that the old techniques work. Second, they must replace the failed techniques with new ones. This process takes time, after years of effort and emotion invested in old techniques. Your life will change when you truly understand the workings of your nervous system and why the techniques that work so well for neurotypical friends and family members don’t work for you.

Use the Right Therapy to Motivate Yourself

If the importance of a task, and the rewards of completing it, don’t motivate a person with ADHD to get things done, what can he use to move him to action? As it turns out, figuring out and embracing his deeply held values can help an individual with ADHD get things done and stay focused when other things have failed.

Michael Manos and his colleagues at the Cleveland Clinic have used Acceptance and Commitment Therapy (ACT) — a third-generation cognitive behavioral therapy developed by Stephen Hayes, Kelly Wilson, and Kirk Strosahi in the late ’80s for people with anxiety disorders — to help people with ADHD get things done.

The subtitle of one of the ACT manuals is “How to Get Out of Your Head and into Your Life.” A big impairment reported by people with ADHD nervous systems is that they spend too much time in their heads because they are confused and hurt by the neurotypical world.

Hayes’s ACT manual works for people with ADHD because it recognizes that the concept of importance — meeting a deadline or doing something that your boss considers important —  is not a motivator for people with ADHD and anxiety. ACT solves the problem by helping people with ADHD use their values — which give their lives meaning and purpose-to motivate them to be productive.

With ACT, patients are asked what matters most to them. What are the important things that give meaning to life? What aspect of their life has made a difference to themselves, to their family, and to their community or their profession? Some people value their family the most. For others, it might be setting a record or gaining fame. For other people with ADHD, it may be faith in God.

I ask my ADHD patients whether they are engaged in something meaningful that reflects their values. I ask them to ask themselves several times a day, “Am I doing something that matters to me?” This puts the person in touch with his values.

Generally, after several weeks of doing ACT, a patient has several ways to access his abilities when he needs them. He knows the paths to success.

Fill Your Toolbox

It is important to remind a person with ADHD that there is more that works about her than is broken. Given the problem-solving abilities of people with ADHD, the compensations they make, and their determination to succeed, it isn’t surprising that only 10 percent or so of people with ADHD are diagnosed and given treatment.

Once newly diagnosed people are on the right medication, I ask them to make an inventory of things they do right — a list of what has worked and has gotten them this far. I ask them to carry paper and a pen with them everywhere they go. When people with ADHD come out of the “zone,” only then do they realize that they were in the zone. I ask them to think about their experience of being engaged, productive, and energized. When did it happen? What took them out of the zone and what got them back in it?

After a month, they will have listed 20 or so techniques that they know work for them. It is their bag of tricks to use when they are procrastinating or being frustrated by their lack of productivity.

Spark Interest When You Aren’t Engaged

If work were always exciting and engaging, they wouldn’t have to pay us to do it. Individuals with ADHD have to create interest where none exists to access their talents and abilities.

A first-year medical student with ADHD was flunking gross anatomy. He saw the course as an onerous task of memorizing 200,000 meaningless names and facts. He had a teacher who saw that he was bright enough to do the work if he could engage with the subject matter.

They tried many things. Then the teacher asked him whom he admired. The student had idolized John Kennedy in his youth. It was the idealism that Kennedy aroused in him that led him to go to medical school.

The teacher asked him to imagine that he had graduated from medical school and was now an emergency room physician at Parkland Memorial Hospital, in Dallas. He asked the student to imagine that they had just wheeled President Kennedy in on a gurney with a bullet wound to the neck, and he had to know the anatomy of the neck perfectly to save Kennedy’s life.

With this technique and others like it, the young man was able to access his intellectual abilities when he needed them. He graduated second in his class. He developed dozens of ways to inject urgency into the tasks of life. He thrived in medicine as a diagnostician, because each patient presented him with a new mystery to solve.

Change the Format of a Task

People with ADHD find it hard to demonstrate what they know to someone else. Many children who know the material aren’t able to show it on a test. They struggle with the ways they are required to demonstrate that knowledge. To tap into their strengths, people with ADHD should look for ways to access their abilities.

A young man with ADHD struggled with writing assignments in his junior year of high school. He had to read books that he would have never chosen himself, and he couldn’t get excited about analyzing these boring books. Each assignment was torture. After encouragement from his parents, he talked with the teacher about another way he could demonstrate his knowledge. He could write parodies of the books he read rather than analyze each one.

This student demonstrated a better grasp of the style, language, and structure of the assigned reading than anyone else in the class. At the end of the year, he was awarded the English department’s prize for best student.

Grab the Reins at School

Adults and kids with ADHD want someone else to put things right or to make things interesting. Usually, if things are going to be interesting and engaging, we have to take steps to make it so.

Be proactive with course assignments. If there are five English courses from which to choose, find out which instructors are bright, engaging, funny, and creative. Sit in on some classes. Ask people who have taken their courses what they are like. An interesting teacher will increase the chance to finish the course and get an A. To insure that a child gets into a desired course, have an accommodation written into his IEP that allows him to register ahead of his classmates and to choose a teacher who works well with ADHD and LD kids.

Create Competition

People with ADHD are able to master new jobs and activities quickly, only to lose interest in the things they just mastered. Challenge and competitiveness can help. Trying to beat a personal best or a rival, or imagining the task as a video game in which you have to get to the next level, can work for many ADHDers.

A man with ADHD worked in quality control at a local bottling plant. He had the mind-numbing job of picking out bottles with defects as they whizzed by on a conveyor belt. He couldn’t focus.

He hit on the idea of imagining that he was going pheasant hunting, one of his favorite sports. He saw the imperfect bottles as birds that might jump up at his feet. His productivity and accuracy improved. When he got tired of pheasant hunting, he imagined hitting a baseball every time he found a defective bottle.

Find a Nudge

Body-doubling is a technique used by tutors. It can help in the workplace, as well.

Fred is an attorney with ADHD who was exhausted from trying to meet deadlines just before they came due. He arranged with his paralegal to manage his time and docket. He kept his desk clear of distractions, and his paralegal brought him one case at a time. They discussed each case and decided what needed to be done before he started on the task. The paralegal checked back every 15 minutes to see if he was still working. At the appropriate time, the paralegal took away the original file, billed the hours, and body-doubled Fred into the next task.

At first, Fred was embarrassed about having a body double, saying, “I feel like a child.” His productivity, billable hours, and improved quality of life soon won him over. “The product is still mine,” he said. “I just need a nudge to get me started.”

Most of these techniques work well for people with ADHD at work and at home. So start today to move forward with your life.

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