Time Management Tips for Adult ADD/ADHD

Adult ADD/ADHD causes more significant impairment than difficulty with mental focus. ADD impairs executive functions including planning, strategizing, impulse control, emotional regulation, and organizational skills.

Time management includes the utilization of all of these skills and thus is often impaired in people with Adult ADD. Patients often miss deadlines, procrastinate, and are often chronically late to appointments and events. This obviously can take a toll on a career, relationships, and family.

Thus, in this newsletter, I am going to provide five tips you can use to help people with Adult ADD who are chronically late.

Tip # 1 – MULTIPLY TIME ESTIMATES BY THREE

ADD often causes people to underestimate the time required for an activity or travel from point to point. When I mention this issue to people with Adult ADD, they often smile because it has been an issue their entire lives. Thus, I recommend multiplying their time estimates by three to build in a buffer against lateness.

Tip # 2 – AVOID "JUST IN TIME" THINKING

Most people hate to wait, but people with Adult ADD find it even more intolerable. Thus, they often plan on arriving just in time to avoid waiting. I help people with Adult ADD recognize this tendency and to adopt a firm policy of arriving early. In order to reinforce this behavior, I encourage them to use the extra time to do something they enjoy such as reading a book, playing a video game, or catching up on emails.

Tip # 3 – MAKE IT A HABIT

For many people with Adult ADD, being late has become a life-long habit. Research has shown that effectively changing a habit takes 21 days of consistent behavior. Often, people I am helping will say that they will be on time for important appointments or projects but not for “important” activities. However, unless people adopt their new habit to all of their activities and projects, the chances of success are much lower. Thus, I encourage people with Adult ADD to treat all projects and appointments equally to change the habit of lateness.

Tip # 4 – BUILD THE DISCIPLINE MUSCLE

Time management requires a significant amount of discipline. Often, people with Adult ADD have been frustrated in so many areas of their lives that they have given up on many challenges or exerting the extra discipline that many tasks require. Discipline is like a muscle and the more you use it, the stronger it develops. I encourage people with Adult ADD to practice discipline in multiple areas of their lives whether it is exercising five more minutes than usual, deciding not to drink that extra cup of coffee, or avoiding the internet and email for three consecutive hours. I have seen people with ADD realize a tremendous amount of success improving their discipline in several areas, including time management.

Tip # 5 – HAVE A SCHEDULE

People with Adult ADD often pack their schedules without allotting time for travel or having a buffer zone. They often don’t have a schedule at all and just improvise. Thus, I encourage people with Adult ADD to use a schedule each and every day of the week. The schedule should consistently include all meetings, projects and tasks as well as blocking out times when projects should be started or extra time to allow for travel. This often helps people with Adult ADD manage their time by improving planning and strategizing.

Please feel free to share these tips with your clients or patients with Adult ADD. Teaching people with Adult ADD time management strategies can make a significant impact on their overall functioning and quality of life.

For more information, contact Dr. Shapiro at 212-631-8010 or scott@scottshapiromd.com.

Scott Shapiro, MD

Assistant Professor of Psychiatry

New York Medical College

Specializing in Adult ADD/ADHD

www.scottshapiromd.com

Bibliography:

Barkley, R., Kevin Murphy. Attention-Deficit Hyperactivity Disorder. A Clinical Workbook. Guilford Press. 2006.

DeLonzor, Donna. Never Be Late Again. A Clinical Workbook. Post Madison Publishing. 2003.

Young, S., Jessica Braham. ADHD in Adults. John Wiley and Sons Ltd. West Sussex, England. 2007

Schema Therapy-Evidence Based Psychotherapy

Have you ever noticed certain patterns in your life such as dating the wrong type of person or getting angry in similar situations? 

Have you wondered why you haven't achieved the success you want in your career or personal life? Do you often feel like an outsider or feel defective?

Schema therapy is a form of cognitive therapy that helps us to understand why we act and feel the way we do.  And, it goes beyond this. It helps you to make changes in your life to feel more satisfied in your relationships, work, and personal life. 

Schemas are life long patterns of feelings and memories that are influenced by our experiences growing up. We all have schemas. Some schemas help us move in the direction of our goals and some schemas thwart our efforts. 

Schema therapy is an interactive and goal oriented therapy that has several components; assessment, experiential, and behavioral. During the assessment, schemas are identified that are interfering in one's life. Then, during the experiential phase, tools such as imagery, flash cards and dialogues are used to deeply understand and recognize how the schemas are interfering in achieving one's goals and how these can be changed. Finally, during the behavioral phase, the therapist and patient works collaboratively on achieving significant changes that are long lasting.

Examples of Schemas:

Defectiveness: You often feel that there is something wrong with you as a person. You don't feel that you are "ok" no matter how successful you are in your life. This schema often occurs if you experienced bullying, chronic criticism, or severe abuse. 

Social Isolation: You often feel like you don't belong or feel uncomfortable with certain groups of people.  This may lead you to avoid social gatherings, certain work environments, or dating. You may also feel so anxious at events that you turn to alcohol or drugs to cope. This schema may occur if you felt different or excluded growing up. This can occur due to differences in ethnicity, religion, finances, or sexual identity.

Self-Sacrifice: You feel that other people's needs are more important than your own. You often ignore your own desires and preferences because you either feel that you don't deserve much or you feel guilty. This schema can develop if we grew up in a family where there was alcohol abuse, a medical illness, or an impaired parent.

Unrelenting Standards: You feel that you must always excel and push yourself to succeed; you may have difficulty relaxing or being spontaneous. People with this schema often struggle with feeling tired, anxious and irritable. This schema develops when excessively high standards are imposed on you during childhood.

Schema therapy addresses and changes long-standing problems such as depression, anxiety, substance abuse, sexual addiction, and personality disorders. To learn more about schema therapy, there is an excellent book written by the founder of schema therapy, Jeffrey Young, PhD, titledReinventing Your Life.

5 Tips to More Satisfying Treatment with Your ADHD Patients

5 Tips to More Satisfying Treatment with Your ADHD Patients

Sometimes, it seems like everybody either has ADHD or thinks they have ADHD. However, only 5% of adult patients have true ADHD. In addition, the symptoms can present differently in adults than they do in children. 

In adults, the most debilitating problems resulting from ADHD are the executive functions such as:  planning, prioritizing, impulse control, maintaining motivation, organizing, and working memory. Patients with ADHD can be frustrating for the patient and their families as well as the doctors who are treating them.

I will describe some of the ways that ADHD can impair our patients' health and safety and then discuss some ways that you can help your patients.

How does impaired executive functioning affect the health of our patients?

1.     Higher risk of substance abuse - 10-25% prevalence

2.     Late or missed medical appointments

3.     Non-compliance or missed medications

4.     Increase impulsivity and risk of contracting STDs

5.     High prevalence of motor vehicle accidents

6.     Underperforming at work

7.     Low self-esteem

8.     Increased risk of depression and anxiety

9.     Difficulty with sleep

10.  Trouble with relationships

5 ways that we can help our patients:

1.     Many patients are often not diagnosed as children. Thus, by using a simple 5 minute screening tool in the office or waiting room, we can help our patients that may have been misdiagnosed as borderline, chronically depressed, anxious or bipolar disorder. 

Here is a site that you can give your patients:

http://counsellingresource.com/lib/quizzes/adhd-testing/adhd-asrs/

Many patients feel that ADHD is not a "real diagnosis" and thus don't get evaluated or treated. However, by explaining to the patients that SPECT and PET scans show differential blood flow in the prefrontal cortex in ADHD patients versus non-ADHD patients can help reinforce to the patient that this is a "real" issue.

2.     Patients with ADHD have difficulty with planning and time management. Thus, they often forget their appointments or are late. 

This can be extremely annoying for a busy clinician, in addition, to the patient not getting the necessary care. 

Thus, a way of improving the show rate for these patients includes encouraging them to write the appointment in their calendars immediately when the appointment is made, requesting that they show up 30 minutes before their appointments, calling them the morning of their appointments (not the night before) and by charging them for missed appointments.

3.     Encouraging your patients to purchase a weekly calendar and to use it on a regular basis instead of relying on post-it notes or on smart phone. Many ADHD patients do better when they see things visually.

4.     Help the ADHD patient to see that they have many strengths and that ADHD is just one aspect of who they are. In addition, even though they have compensated for it most of their lives, validate that it may have been a difficult struggle and that it can get better.

5.     Help the patient to understand that many of their behaviors such as underperforming at work, engaging in high risk sexual activity, or challenges in their relationships are very common in patients with ADHD and that this can get better over time with treatment, either medications or behavioral treatments.

Working with patients who have ADHD can be frustrating at times, but can be extremely rewarding. Just like cigarette cessation, it can have a significant impact on a patient's life, but with appropriate diagnosis, treatment, and intervention, a patient's health and well-being can greatly improve.

Scott Shapiro, MD

www.scottshapiromd.com

212-631-8010

Bibliography:

Barkley, R., Kevin Murphy. Attention-Deficit Hyperactivity Disorder. A Clinical Workbook. Guilford Press. 2006.

Young, S., Jessica Braham. ADHD in Adults. John Wiley and Sons Ltd. West Sussex, England. 2007

Adult ADHD and Insomnia

Adult ADD/ADHD and Insomnia -

Insomnia is very common in Adult ADD/ADHD and often overlooked by professionals. Also, insomnia is often under-reported and under-treated since patients are often focusing on other medical issues when they visit their doctor or they haven't found relief from their insomnia from previous treatment.

Insomnia and chronic sleep deprivation can have a significant impact on many areas of a person's life including.

- Decreased job performance

- Impaired focus and concentration

- More frequent car accidents

- Increased risk of suicide

- Worsening health condition

- Poor medication compliance

By addressing and treating a person's insomnia, you can make a great impact on the quality of life. There are many causes of insomnia and many of them are overlapping. Some of the most frequent causes include:

- Working late

- Computer, Internet, IPAD before bed

- Exercising in the late evening

- Depression and anxiety

- Reflux

- Restless leg syndrome

- Sleep Apnea

- Substance abuse

- Medications ex. antidepressants, stimulants, steroids

In addition, insomnia is very common in psychiatric problems such as depression and anxiety. “A useful rule of thumb is that insomnia more commonly precedes a depressive episode, and more commonly follows an episode of anxiety”¹.

When a patient presents with a sleeping problem, it is crucial to understand the potential cause(s) of the sleeping problem.

Here are ten essential questions to ask:

When did your sleeping problem start?

Are there any changes at work or home?

Have you started any new medications or supplements?

When do you work out?

Do you snore or kick your partner?

Have you had this problem before?

What treatments have helped in the past?

What medical problems do you have?

Do you have a history of depression, anxiety or ADHD?

How many times a week do you drink? What do you like to drink?

There are numerous treatments available for insomnia. A key principle to keep in mind is that “…[N]onpharmacologic therapy for insomnia should be attempted first, and benzodiazepines should probably be reserved for patients not responding to nonpharmacologic combined with nonbenzodiazepine pharmacologic therapy.”²

Here are some tips on medications that I have found helpful for my patients:

1. Ambien is an intermediate acting medication. It should be taken on an empty stomach. It is recommended to use for only 2 weeks, but often I have found that patients require longer periods of use.

2. Sonata has a very short half-life. Thus, it is useful for the patients that are able to fall asleep but wake up at 4 or 5 am and need an additional 2-3 hours of sleep without a hangover. This also should be taken on an empty stomach.

3. I rarely use Lunesta because it has a high rate of the side effect of a metallic taste. This occurs in 40% of patients.

4. Another medication that I often like for patients is Trazodone. This is an off-label use. I prescribe 25- 100 mg at night. There is a risk of hypotension and thus a risk of falls. I rarely use it in men because of the risk of a priapism. If it is used with men, this risk must be discussed with the patient prior to prescribing.

5. Seroquel is another medication that I prescribe off-label. Even though there is a risk of metabolic syndrome and other side effects, I have found this medication to be very help, especially in patients with PTSD, bipolar disorder or chronic insomnia.

6. I try to avoid benzodiazepines such as Klonopin (clonazepam) and Xanax (alprazolam) because they often help with anxiety and insomnia initially; however, the sedative effect often wears off over time.

7. Tricyclic antidepressants such as Tofranil may also be helpful in small doses. Some of the common side effects include dry mouth and constipation.

8. Clonidine 0.1-0.2 mg can be an effective off-label treatment for insomnia, especially in patients with Adult ADD/ADHD and PTSD.

Insomnia is very common and a careful history and assessment along with effective treatments can greatly help your patient have a better quality of life.

Scott Shapiro, MD is a Harvard-educated psychiatrist in New York City. He specializes in Adult ADHD and Cognitive Behavioral Therapy (CBT). Learn more about Dr. Shapiro at www.scottshapiromd.com or call 212-631-8010.

References:

1. Flaherty, Kelleen. The Carlat Report, November 2011, Vol 9, Issue 11.

2. Smith, Howard, et. al. American Journal of Therapeutics. 18 (3): 227-40, May 2011.

Disclaimer

The material contained here is not intended in any way to replace proper medical supervision or advice. All decisions which may impact your health should be discussed with your physician.

If you are under the care of a physician or are taking medication, consult your physicians before changing or discontinuing any medication or current medical treatment. Implementing new items may alter your medication needs. Adjustments of prescribed medications should only be done under the direct supervision of your physician.

Information on this site is provided for informational purposes and is not meant to substitute for the advice provided by your own physician or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disease, or prescribing any medication. If you have or suspect that you have a medical problem, promptly contact your health care provider.
All photos included in the header of this site are models and are in no way associated or under the care of Dr. Shapiro.