Are We Afraid of Adderall?

Introduction

I sometimes wonder if the treatment of ADD/ADHD didn’t involve stimulants if there would there be such a fear of diagnosing Adult ADD/ADHD. Effective screening and treatment for Adult ADD/ADHD is essential to provide the highest level of care to your clients.

Many people question whether or not Adult ADHD exists as a legitimate diagnosis. Indeed, many claim that ADD is over diagnosed and that stimulants are overprescribed. Psychiatrists are afraid of becoming one of these doctors who “overprescribe”. Despite the fact that stimulants are the standard of treatment for Adult ADD, whether or not someone has ADD should not hinge on the treatment, but instead on the proper assessment and diagnosis.

Are some people misdiagnosed as having ADD but in fact have another condition? Sure. And many people, notoriously college students, use stimulants to improve their performance or energy.

However, more often than not, Adult ADD is under-diagnosed and under-treated. Adult ADD affects at least 5% of the population and it is estimated that nearly 75% of Adults with ADD never receive an accurate diagnosis or effective treatment. An estimated 3 percent to 5 percent of U.S. adults have ADHD, but only 15 percent are aware they have the disorder, according to Rafael Klorman, a professor of psychology and director of clinical training at the University of Rochester in New York and one of the briefing’s speakers. (Steven Reinberg, Healthday, Internet, Sept 9)

Dr. David L. Katz, the director of the Prevention Research Center at Yale University’s Schools of Public Health and Medicine, said, “Available data indicate we are concomitantly under-diagnosing and over-diagnosing ADHD, under- and over-treating it.”

Costs of Missing the Diagnosis

ADD causes significant lifelong impairment in those it affects. Left untreated, it affects financial status, educational achievements, relationships and even health.

“Overall, people with ADHD have less annual income,” Biederman said. “This was true for males and females. Those with ADHD had income approximately $10,791 lower per year among high school graduates, and about $4,334 lower for college graduates than their counterparts without ADHD.”

The estimated yearly income loss for adults with ADHD in the United States is $77 billion, Biederman said. The numbers for drug abuse are $58 billion, for alcohol abuse $85 billion, and depression $43 billion, he said. “You can see that ADHD is one of the costliest medical conditions we have,” he said.

I have seen hundreds of patients over the years who have suffered for decades with ADHD. Some of them have may have suspected that something wasn’t quite right or that school and life was more difficult for them than their peers. When they start to learn more about ADHD, realize that their challenges are due to ADHD and discover that there are effective treatments, they are often left wondering why their teachers, parents, and previous therapists or psychiatrists didn’t pick up on the ADHD.

For example, the other day, I saw a 26 year-old* who had been referred by his law school advisor for anxiety and depression. This client never suspected that he had ADHD. He had performed well in high school and college and had even been accepted into a leading law school. However, it wasn’t done without a huge price to pay. He was extremely anxious and fearful of failing. Hence, he would spend an inordinate number of hours studying, worrying and preparing. Other therapists and psychiatrists had diagnosed him with depression, OCD, or generalized anxiety disorder and attempting to treat his symptoms with antidepressants and benzodiazepines. These medications would make him feel depressed, lethargic, and foggy.

As I explored his history, he told me that he was always well behaved as a child but would often daydream in class. He had difficulty socializing with his peers and felt like “the other kids were playing by rules that he was never taught”. People often call him space cadet, and his parents had him tested several times for his hearing because he seemed not to listen. He was always losing his school supplies and had a messy desk and room. He did not do well in elementary school and his parents often yelled at him about his poor grades and not doing his homework. They hired tutors for him and set a very rigorous and regimented schedule of studying that continued throughout junior high and high school. He started earning good grades and was proud of his performance, but he still couldn’t understand why it seemed to take him 2-3 times more time to do his work than it took his peers.
He often had difficulty going to sleep at a regular hour and waking on time was nearly impossible. He was chronically a few minutes late to school, which almost lead to his dismissal.
Since he was very forgetful, he took copious notes in class and would keep lists of all of his “to do” items. Since he kept so many to-do lists and reviewed information on a regular basis to “keep from forgetting”, one psychiatrist had diagnosed and treated him with OCD.

When he went off to college and struggled a without the rigid structure that his parents and school had imposed on him, he enlisted tutors to help him with his classes and went to the writing center for assistance. He didn’t have much time to participate in collegiate social life because he was constantly studying. Yet his grades were mediocre and he suffered from bouts of anxiety and depression.
He said that he always had difficulty organizing and with time management. He was chronically late to all of his classes and appointments saying “he just didn’t have a good sense of time”.

My client was determined to go to law school and had difficulty with application process and keeping up with all of the details. He did get accepted to a lower-ranked law school and decided to go. With the new demands of law school, his previous coping strategies were starting to fail. He was getting further behind when he was finally referred to me for an assessment.

As it turned out, he did not have depression, anxiety or OCD, but he had ADHD. Interestingly, he had a cousin, a brother, and an aunt who all had been diagnosed with ADHD and were on treatment. They all had had the hyperactive type of ADHD and also had alcohol abuse problems. His parents were shocked that their son had ADHD because he always seemed to be so well behaved and fastidious about his schoolwork.

In addition he related to me how he walked around in a fog most of the day and felt that he had cobwebs in his brain, the way that someone might when they first wake up in the morning or when they have the flu. However, this was how he had felt his entire life and assumed this was how other people also felt. He didn’t realize that some people are able to focus, concentrate and stay on task without the need to rely on an excessive amount of effort and anxiety.

I started him on Adderall. All of a sudden, a light bulb went off, the cobwebs cleared, and he saw the world the way that most people do. In addition, his anxiety greatly diminished and finally had the hope to pursue his passions and life goals. Did he continue to keep copious notes, make lists and experience some anxiety? Did he still have trouble with forgetfulness and organization? Absolutely. Medications are not a total cure. However, as he continued to use the coping strategies that had painfully served him throughout his life, he also worked with an ADHD coach to help prioritize, learn additional strategies, and develop realistic expectations. In addition, he worked with a therapist who addressed with him other sources of his anxiety and developed realistic goals and expectations, taking into account his strengths and weaknesses.

How do you diagnose Adult ADD/ADHD?

Adult ADD/ADHD is a clinical diagnosis made by a therapist, neuropsychologist, psychiatrist, or other health care provider. It is important that whoever makes the diagnosis has experience with Adult ADD/ADHD. Many clinicians were taught that if someone presents with depression and ADHD, first treat the depression THEN treat the ADHD. Very often, the patient relates feeling depressed and frustrated; often this is because he has experienced one failure after another or jumped from one job to the next. In our experience at The Hallowell Center, when you treat the ADHD, the client or patient develops the ability to achieve his or her goals, improve relationships, meet deadlines, remember to pick up the children, avoid accidents on the road, remember the passport before driving to the airport and generally feel more competent, confident and happy.

Unfortunately, when patients are treated for depression with antidepressants, or worse, treated with atypical antipsychotics for bipolar disorder and kept on these medications for months or years, their symptoms often do not improve and indeed may worsen. I have never actually seen this data in the professional literature, but during my training at Massachusetts General Hospital, I was taught a VERY important lesson. Never, never, never take away a patient’s dopamine. Dopamine gives us zest for life, motivation, and enables us to pay attention. It is the piece of the puzzle people with ADHD may be missing that inhibits and often blocks them from their full potential. Antidepressants and antipsychotics, through a feedback loop, can decrease the function of dopamine in the frontal lobes and limbic system, exacerbating ADD symptoms.

In some instances, neuropsychiatric testing can be useful, especially when there is a suspicion of a learning disorder, such as dyslexia. However, testing is not always indicated nor is it always accurate. It is generally time consuming, very costly, and may miss the diagnosis. Testing may show that a person’s executive functioning, focus and distractibility are normal, but testing is performed over a short period of time. A key feature of adult ADD is that the symptoms are consistently inconsistent! The challenge that ADD presents is lack of sustained attention, focus and executive skills both throughout the day and over prolonged periods of time. Thus, one may function fairly well during neuropsychiatric testing over a brief period of time and with prompting from the tester, but may not be able to do this for extended periods of time. Neuropsychiatric testing is useful in complex cases or where the diagnosis is equivocal. However, it is important to recognize that someone may have clinical ADD even though testing was negative, much in the same way that someone may clinically have seizure disorder, despite a negative EEG.

How to Help Our Clients with Adult ADD/ADHD-Five Key Tips

1. Screen All Clients

So, how can we help our clients who have Adult ADD/ADHD? First, it is important to understand the impact that ADD/ADHD has on someone’s life and that it is frequently misdiagnosed or under-diagnosed. It is important to understand that ADD/ADHD does exist and that the stigma of ADD/ADHD and the anxiety about using stimulants keeps people from getting diagnosed and treated.
It is important to screen all clients for Adult ADD/ADHD by using a simple five minute screening tool in the office or waiting room.
Here is a site that can be utilized as a screening tool:

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

Many of our clients also feel that Adult ADD/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. Refer For An Assessment and Treatment

With a client where there is a high suspicion of Adult ADD/ADHD, refer to a psychiatrist or psychologist who specializes in ADD/ADHD for assessment and treatment. Medications are a cornerstone of treatment and can be life changing for many patients who have been suffering for decades with an inaccurate diagnosis and without effective treatments.

3. Cognitive Behavioral Therapy

Another cornerstone of treatment is developing specific strategies to address the specific challenges with the individual case. “Cognitive behaviour therapy has been successfully applied to this client group even with minimal contact (Stevenson et al., 2002; Wilens et al., 1999). “Individuals with ADHD require structure in terms of personal organization, social boundaries, and practical help to cope with everyday problems” (Susan Young, 2007, pp 50)

By using CBT in session with your client, you can help them address their most important challenges. Often, these challenges include difficulties with time management, prioritizing, strategizing, planning, mood regulation, social skills, organization, focus and motivation.
It is very helpful to encourage your clients 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.

Another behavioral intervention for your clients is to teach them to develop a to-do list with a way to prioritize each item. Then, have them place the items on a specific time on the calendar. More structure can facilitate better outcomes.

If you do not specialize in CBT or the client is having significant career challenges, hiring a coach to help the client overcome these specific challenges, develop strategies and increase accountability can help to increase success in work and personal life. Coaching can be an essential piece of treatment but it can be difficult to find an effective coach. Ideally, the coach should have extensive experience with working with clients who have Adult ADD/ADHD.

4. Address the Shame and Instill Hope

Growing up with diagnosed or undiagnosed ADD/ADHD can create significant shame for your client. There is often significant shortfall in academics, career history and relationships as well as frequent criticism or ridicule from parents, teachers, and peers.

Help the ADHD client to see that they have many strengths and that ADHD is just one aspect of who they are. In addition, they have compensated for it most of their lives. Validate that it may have been a difficult struggle and that their lives can improve significantly.

5. Minimize the Potential Fallout from ADD/ADHD

Even when a client understands some of the challenges that ADD/ADHD has created, it is often not clear how it has impacted other areas of their life. Help the client understand that many of their behaviors such as underperforming at work, engaging in high risk sexual activity, or facing struggles in their personal relationships are very common in patients with ADHD. Reassure them that this can improve over time with treatment, medications, behavioral treatments, or a combination.

Conclusion

ADD/ADHD is a serious disorder that affects all aspects of a client’s life. Many of your current or future clients may not have received an accurate diagnosis or treatment for ADD/ADHD. Understanding that ADD/ADHD does not necessarily equal Adderall is imperative. Overcoming the stigma that implies ADD/ADHD is not a “real diagnosis” and understanding the significant impact that it has on a client’s life and course of their therapy can make a substantial difference to your client. In addition, screening for Adult ADD/ADHD in each of your clients, referring them for assessment and treatment, and utilizing cognitive behavioral therapy can make a significant impact on their lives.

*Disclaimer: Details of cases have been altered to protect the confidentiality of any and all individuals.
References:
Reinberg, Steven. Adult ADHD Costs Billions in Lost Income. HealthDay Reporter at HealingWell.Com. 2004. Retrieved from http://www.news.healingwell.com/indesx.php?p=news1&id=521145
Young, Susan et al.: ADHD in Adults; A Psychological Guide to Practice. John Wiley and Sons, Ltd. 2007
Wilens,T.E. Cognitive therapy in the treatment of adults with ADHD: a systematic chart review of 26 cases. Journal of Cognitive Psychotherapy: an International Quarterly, 13, 215-226.

7 TIPS TO IMPROVE PRODUCTIVITY

Being more productive doesn't necessarily mean working longer hours or working faster. To me, it means working more efficiently and effectively. Below are 7 tips that I teach my patients to help them be more productive.

1. Create Your Schedule The Night Before

Many people start their work day spending a lot of time trying to figure out where to start, surfing the Internet, or chatting with colleagues. A great way to start your day with a bang is to write out a schedule the night before. This is not your calendar, but may include some of those items. Focus on your top priorities and anticipate any obstacles.

2. Under-promise and Over-Deliver 

Many of us are overly optimistic about what we can accomplish in a day. Thus, we promise our managers, families, and ourselves that we will get "just one more thing" done. This can create constant pressure and take the "wind out of our sails" when we don't deliver. I recommend that people promise or commit less and then as they are working, to over-deliver. This allows for more success and improved productivity.

3. Cluster Tasks

Answering phone calls, checking emails, and surfing the Internet are huge time sinks in our days. Thus, cluster certain tasks to specific times of day. For example, you might decide to check your emails only once in the morning and once in the afternoon. This allows your to focus on your key priorities without constant interruptions.

4. Reward Yourself

Research shows that rewarding yourself improves productivity and consistency. No matter how small the task is, say to yourself "Good Job" after you have started a business proposal, returned a phone call, or completed filing a pile. When it is a larger project or goal, you might reward yourself with a walk around the park, going out to lunch with a friend to a special restaurant, or going for a massage. It is more important to acknowledge your "wins" than the actual reward.

5. Write Out the Steps

There are many tasks or projects we avoid because they seem daunting or confusing. An effective way to overcome this is to take out a sheet of paper and start writing out the steps. The exact order doesn't matter. If you don't know how to do a particular step, write out "find out how to....". You might also work with a colleague or friend to discuss what the steps are. REMEMBER: Write it out. Don't just discuss the great ideas. Then, decide what the first steps are. After you have some momentum, you can organize the steps and add any additional items.

6. Create Goals

Create goals for different time periods including the year, quarter, and month. The most effective goals are specific and have a deadline. Also, by writing them in the present tense, it sends the message to yourself that you are going to complete it. For example, "I am reaching my sales goal of $500,000 by December 31st."

7. Develop Protocols

For tasks or projects that are repeated, develop a protocol. If there are ten steps for a specific task, write out a protocol that includes each of these steps. This improves the motivation to do a certain task and also ensures that nothing slips through the cracks. It also allows the task to be accomplished more quickly.

SEVEN PEARLS FOR EFFECTIVE COGNITIVE BEHAVIORAL THERAPY

SEVEN PEARLS FOR EFFECTIVE COGNITIVE BEHAVIORAL THERAPY


Research has proven that by identifying our distorted thoughts and beliefs, we can have better control over thoughts, thus better control over our feelings. Having distorted thoughts or beliefs doesn't mean that there is something wrong with us. We all have distorted thoughts and beliefs at different times in our lives. 

Some examples of distorted thoughts:



OVER-GENERALIZING: At times, we may see things as all-or-nothing. For example, if one thing goes wrong with a project, we may think that the entire project is a failure. Or, if there is one thing that upsets us about a person, we may decide we don't care for that person at all.



MIND READING: We assume that we know what someone is thinking. We may tell ourselves that someone thinks we are "stupid" or does not like us even though there is no evidence that supports this thought. This is called mind reading.



CATASTROPHIZING: We exaggerate how "awful" something is or imagine the worst possible outcome. Perhaps our boss wants to speak with us and we catastrophize that we are going to be fired. Or, it rains on one of the days of a vacation and we think "this is the worst thing that could have happened".



FORTUNE TELLING: We think we know for sure what is going to happen. For example, we tell ourselves, "I know I am not going to get that promotion" or "I won't be able to handle that assignment". 

In addition, specific behaviors or skills are taught including social skills, assertiveness, organizational skills, and relaxation techniques. These are taught during and between sessions. 

   

Below, are seven pearls that I will share with you that I have found helpful over the years in my practice:

  

1. DISCUSS GOALS OF TREATMENT

During the initial assessment phase, it is important to collaborate on the goals of treatment. This helps keep the treatment focused and productive. Without goals, therapy can end up focusing on whatever problem is coming up that week and can interfere with progress of the original presenting problems. Sometimes, the patient may not be able to specifically describe a goal except a vague "I want to be less anxious" or "I want to feel happier".  This is fine at the beginning. However, over the first couple of months, you should return to this discussion about goals to see if they can be described in more specific terms. 

For example, if someone presents with depression, the goals may include the following: Finding a more fulfilling job, returning to college, exercising three times a week, making two new friends, and stopping the use of marijuana.

2. START EACH SESSION WITH AN AGENDA

Every session should start with an agenda that is discussed collaboratively between the therapist and the patient. Again, this helps to keep the session focused and more effective. The agenda should include following up on homework from the previous session, a check-in about the mood and week, bridging or reviewing the topics and progress from the previous session, and topics related to discuss in the current session that is related to a specific goal.

3. DISCUSS WHERE TO ADDRESS THE ISSUE

Most therapy goals will have several components including distorted thoughts, beliefs or behaviors. Thus, during the session, collaboratively decide on which level to address the goals. If you are working on distorted thoughts, it is important to elicit what thoughts or images occur that are leading to the distress, such as anxiety, low mood, or blocking a certain behavior. If you are working on certain behaviors such as social skills or relationship issues, it is important to discuss when the skills will be used and how likely it is the skills will be used. Another useful technique for addressing behaviors is role playing and visualizing which helps to practice the skills and address any blocks or anxieties around the behavior.

4. USE FLASHCARDS

Flashcards can be used to remember the key points of the session or a mantra that may help with certain thoughts or feelings. If I am working with a patient who is struggling with depression, I will title the flashcard something like "Survival Kit" and it will include strategies to cope with the depression such as reaching out to a friend, getting out of the house, reaching out to me, or taking care of a small chore.

5. STAY FOCUSED

At the beginning of treatment, goals for therapy are discussed. Sometimes, the therapy session may head in a direction that is unrelated to any of the goals of treatment. This is appropriate at certain times, but if this is happening every session and for the entire duration, then there can be a limit to the progress of therapy. Structure is important in CBT, but flexibility is also important. This would be a time to collaborate to discuss whether to continue on the current diversion or issue that is being discussed or go back to what was discussed in the agenda.

6. ASSIGN HOMEWORK

Towards the end of each session, a collaborative discussion takes place about homework or "action tasks" to perform between sessions. An action task might be to buy a calendar if one of the issues is time management or recording thoughts and images that occur during stressful periods in a notebook to discuss and address at the following session. Always make sure to follow-up on the homework or action task at the next session or it creates the impression that working on problems or goals in between sessions is not a crucial part of getting better.

7. ASK FOR FEEDBACK

Towards the end of the session, ask what went well during the session, what could have gone better, and what the main take-away messages are. This helps to build the alliance, improve future sessions, and maximize progress.

Cognitive behavioral therapy is an extremely effective form of therapy, either with or without medications and is an excellent way to practice psychiatry.

 

If I can be of help or you have any questions about cognitive behavioral therapy, adult ADHD or medications, please feel free to email me at scott@scottshapiromd.com or call 212-631-8010.

Scott

Scott Shapiro, MD, FAPA

First FDA Approved Scan for ADHD--7 Things to Know about ADHD and Brain Scans

The FDA recently approved the first mental health diagnosis to use a brain scan called an electroencephalogram, or EEG, that measures electrical impulses in the brain.  The EEG records different brain wave patterns including alpha, beta, delta, and theta waves.

In children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD), the ratio of theta to beta waves has been shown to be higher. The FDA approved test is called the NEBA, the Neuropsychiatric EEG-Based Assessment Aid System.

The study used to receive FDA approval included 275 children and adolescents. The study concluded that NEBA can assist in the diagnosis of ADHD amongst children and adolescents.

Here are 7 Things to Know about NEBA:

1.    The test takes 20 minutes to complete.

2.    As with all tests results such as labs and x-rays, the information should be used with other clinical assessments such as a psychiatric evaluations and questionnaires.

3.    This test has only been approved in people aged 6-17 years old.

4.    It has NOT been approved for adults but may eventually prove beneficial.

5.    In the future, more sophisticated scans such as the functional MRI (fMRI) may aid in the diagnosis of ADHD. 

6.    Eventually, the NEBA may assist in other mental health assessments such as depression, bipolar disorder, and autism.

7.    In my opinion, further research is necessary prior to recommending the NEBA due to the limited size of the study.

The NEBA is the first FDA-approved scan to assist in a psychiatric diagnosis and eventually may be used for other disorders. In addition, it could lead to further research in using more sophisticated scans in the diagnostic process. At this time, I feel further research is necessary before using this tool clinically.

Resources:

Goldberg, Dan. Brain wave scan, approved by FDA, could help detect ADHD. Star-Ledger On-Line. July 17, 2013.

Park, Alice. Reading the Brain: FDA Approves First Scan for Diagnosing ADHD. Time Magazine On-Line. July 16^th, 2013.

5 Easy Steps for Diagnosing Adult ADHD

5 Easy Steps for Diagnosing Adult ADHD

The proper diagnosis of Adult ADHD can be confusing and overwhelming; many of the symptoms overlap with other disorders and many of the symptoms are set along a wide spectrum. Additionally, most clinicians have not been extensively trained in the accurate diagnosis of Adult ADHD.

This is a brief and simple step-by-step guide to the diagnosis of Adult ADHD so that you can feel more confident in assigning the diagnosis and referring to a therapist and/or psychiatrist who specializes in the comprehensive treatment of Adult ADHD.

 Step 1: Ask these key screening questions:

1.  Do you have difficulty reading magazines, books, or maps?
2.   Do you have a messy office or home?
3.   Do you have trouble starting and/or completing projects?
4.   Do you often feel mentally “foggy” or “in a haze”?
5.   Do others say you tend to jump from topic to topic in conversation?
6.   Have you received negative feedback, such as inconsistent performance, in your school or work reviews?
7.   Have you had any or all of these problems since childhood?
8.   Which family members, if any, have depression, anxiety, mood swings, or problems with attention and focus?

Step 2: Administer the ADHD Screening Exams called the ASRS v1.1 and the Epsworth inventory on all patients.

Step 3: Gather collaborative information:

Many young adults may try to receive a diagnosis of ADHD in order to get stimulant medications even when they do not have ADHD, so it is critical to review collaborative information whenever practical. 
Assess past report cards and performance reviews for clues pointing toward ADHD.
Always speak to family members, whenever possible.

 Step 4: Administer the Conners Test

This is the gold standard for inventories and is, in fact, superior to neuropsychiatric testing. The diagnosis of ADHD is a clinical diagnosis and does not require neuropsychiatric testing unless you are also evaluating for learning disabilities. 

Step 5: Rule out medical or psychiatric disorders that can mimic or coexist with Adult ADHD:

There are many medical and psychiatric disorders that can mimic the symptoms of Adult ADHD. These are a few conditions that may exhibit similar symptoms:
1.   Chemotherapy
2.   Menopause
3.   Sleep apnea
4.   Insomnia
5.   Bipolar Disorder, depression or substance abuse
6.   Medications such as blood pressure medications and antibiotics
7.   Multiple Sclerosis, seizures, HIV, head injuries

How do you distinguish these scenarios from Adult ADHD?  After taking a detailed history, determine whether the symptoms began after early adolescence. If so, it is NOT ADHD. If the symptoms fluctuate, it is NOT ADHD.

It should be noted that in certain situations, such as menopause, depression, or chemotherapy, stimulants are commonly used and are effective for the treatment of poor focus and attention, distractibility, and low motivation. 


Following these simple steps, you as a clinician can more effectively diagnosis and refer your patients who most likely have Adult ADHD or present with similar symptoms. It is important that this provider has had specialized training in the diagnosis and treatment of Adult ADHD.

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.