The Management of
Adult Attention Deficit Disorder

by Edward M. Hallowell, M.D. and John J. Ratey, M.D.

The treatment of Attention Deficit Disorder (ADD) begins with hope. Most people who discover they have ADD, whether they be children or adults, have suffered a great deal of pain. The emotional experience of ADD is filled with embarrassment, humiliation, and self castigation. By the time the diagnosis is made, many people with ADD have lost confidence in themselves. Many have been misunderstood repeatedly. 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 ADD 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 people with ADD 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, individuals with ADD 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 ADD 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 ADD into five basis areas:

1. Diagnosis
2. Education
3. Structure, support, and coaching
4. Various forms of psychotherapy
5. Medication

In this article we will outline some general principles that apply both to children and adults concerning the non-medication aspects of the treatment of ADD. One way to organize the non-medication treatment of ADD is through practical suggestions.

50 TIPS
INSIGHT AND EDUCATION:

1. Be sure of the diagnosis. Make sure you're working with a professional who really understands ADD and has excluded related or similar conditions such as anxiety states, agitated depression, hyperthyroidism, manic depressive illness, or obsessive compulsive disorder.
2. Educate yourself. Perhaps the single most powerful treatment for ADD is understanding ADD in the first place. Read books. Talk with professionals. Talk with other adults who have ADD. You'll be able to design your own treatment to your own version of ADD.
3. Coaching. It is useful for you to have a coach, for some person near to you to keep after you in a supportive way. 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, on your side. A coach can be tremendously helpful in treating ADD.
4. Encouragement. ADD 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 ADD adult withers without encouragement and positively thrives when given it. The ADD adult will often work for another person in a way he won't work for himself. This is not "bad," it just is. It should be recognized and taken advantage of.
5. Realize what ADD is NOT, i.e., conflict with mother, etc.
6. Educate and involve others. Just as it is key for you to understand ADD, it is equally, if not more important, for those around you to understand it--family, friends, people at work or at school. Once they get the concept they will be able to understand you much better and to help you out as well. It is particularly helpful if your boss can be aware of the kinds of structures that help people with ADD.
7. 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.
8. Listen to feedback from trusted others. Adults (and children, too) with ADD are notoriously poor self observers. They use a lot of what can appear to be denial.
9. Consider joining or starting a support group. Much of the most useful information about ADD has not yet found its way into books but remains stored in the minds of the people who have ADD. In groups this information can come out. Plus, groups are really helpful in giving the kind of support that is so badly needed.
10. 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 ADD. A good psychotherapist may help in this regard. Learn to break the tapes of negativity that can play relentlessly in the ADD mind.
11. 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.
12. Remember that what you have is a neurological 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 ADD have great trouble accepting the syndrome as being rooted in biology rather than weakness of character.
13. Try to help others with ADD. You'll learn a lot about the condition in the process, as well as feel good to boot.
    
    Performance Management
    
14. External structure. Structure is the hallmark of the non-pharmacological treatment of the ADD child. It can be like the walls of the bobsled slide, keeping the speedball sled from careening off the track. Make frequent use of:
    1) notes to self - 2) color coding - 3) rituals - 4) lists - 5) reminders - 6) files
15. Color coding. Mentioned above, color coding deserves emphasis. Many people with ADD 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.
16. Use pizzazz. In keeping with #15, try to make your environment as peppy as you want it to be without letting it boil over.
17. Set up your environment to reward rather than deflate. To understand what a deflating environment is, all most adult ADDers 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.
18. Acknowledge and anticipate the inevitable collapse of x% of projects undertaken, relationships entered into obligations incurred.
19. Embrace challenges. ADD 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.
20. Make deadlines. Think of deadlines as motivational devices rather than echoes of doom. If it helps, call them lifelines, instead of deadlines. In any case, make them and stick to them.
21. 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 ADD. 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.
22. Prioritize. Avoid procrastination. When things get busy, the adult ADD 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 ADD. You have to really discipline yourself to watch out for it and avoid it.
23. Accept fear of things going too well, accept edginess when things are too easy, when there's no conflict. Don't gum things up, just to make them more stimulating.
24. 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 ADD can do their best under rather odd conditions. Let yourself work under whatever conditions are best for you.
25. 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 ADD need to be doing several things at once in order to get anything done at all.
26. 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. 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.
27. Leave time between engagements to gather your thoughts. Transitions are difficult for ADDers, and mini-breaks can help ease the transition.
28. 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.
29. 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.
    
    Mood Management:
    
    
30. 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.
31. Recharge your batteries. Related to #30 most adults with ADD need feeling guilty about it. One guilt-free way to conceptualize it is to call it time to recharge your batteries. Take a nap, watch TV, meditate. Some-thing calm, restful, at ease.
32. Choose "good," helpful addictions such as exercise. Many adults with ADD have an addictive or compulsive personality such that they are always hooked on something. Try to make this something positive.
33. 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.
34. Related to #33, recognize the following cycle which is very common among adults with ADD: Something "startles" your psychological system, a change or transition, a disappointment or even a success. The precipitant may be quite trivia. b. This "startle" is followed by a mini-panic with a sudden loss of perspective, the world being set topsy-turvy. c. 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.
35. 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 ADD blues. They will soon pass. You are OK."
36. Expect depression after success. People with ADD 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 ADD misses the conflict, the high stimulus, and feels depressed.
37. Learn symbols, slogans, sayings as shorthand ways of labeling and quickly putting into perspective 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 ADD 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.
38. Use "time-outs" as with children. When you are upset or over stimulated, take a time-out. Go away. Calm down.
39. Learn how to advocate for yourself. Adults with ADD are so used to being criticized, they are often unnecessarily defensive in putting their own case forward. Learn to get off the defensive.
40. 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.
41. 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.
42. Remember that ADD usually includes a tendency to over focus or hyper focus at times. This hyper focusing 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.
43. Exercise vigorously and regularly. You should schedule this into Your life and stick with it. Exercise is positively one of the best treatments for ADD. 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 bene- fits 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 you life.
    
    Interpersonal Life
44. Make a good choice in a significant other. Obviously this is good advice for anyone. But it is striking how the adult with ADD can thrive or flounder depending on the choice of mate.
45. 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.
46. Schedule activities with friends. Adhere to these schedules faithfully. It is crucial for you to keep connected to other people.
47. Find and join groups where you are liked, appreciated, understood, enjoyed. People with ADD take great strength from group support.
48. Reverse of #47. Don't stay too long where you aren't understood or appreciated. Just as people with ADD gain a great deal from supportive groups, they are particularly drained and by negative groups.
49. Pay compliments. Notice other people. In general, get social training, as from your coach.
50. Set social deadlines. Without deadlines and dates your social life can atrophy. Just as you will be helped by structuring your business week, so too you will benefit from keeping your social calendar organized. This will help you stay in touch with friends and get the kind of social support you need.

This educational material is made available, courtesy of the author and a non-profit organization based in Tacoma, WA. whose purpose is to educate adults, and the professionals who treat them, about Attention Deficit Disorder. We have numerous materials as well as a quarterly newsletter for sale. Our address is: ASW, PO Box 7804, Tacoma, WA. 98407-0804. Msg. Tel. 253-759-5085, email: addult@addult.org and web site: www.ADDult.org."

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