Episode 030: All About ADHD - Part X
Isabelle & David welcome Isabelle’s husband, Bobby, and their friends, Christina, AJ, and Gabe, to continue to listen and learn from David’s tried and tested presentation on ADHD, which he normally gives to fellow clinicians (for the 1st-9th parts of this talk, please see episode 4, All About ADHD Part I; episode 6, All About ADHD Part II; episode 9, All About ADHD Part III; episode 12, All About ADHD Part IV; episode 15, All About ADHD Part V; episode 18, All About ADHD Part VI; episode 21, All About ADHD PART VII; episode 24, All About ADHD Part VIII; episode 27, All About ADHD Part IX). David launches right into why we get into fights when we leave and we procrastinate, imagine a scalloping bar graph that shoots right near the end, and then right back down. David uses the example of how when assigned a paper, he realizes he has three weeks to work on it, so he plays video games, he does other things, and then his anxiety grows as he gets closer to the deadline, and then it shoots up very rapidly, and he goes into “oh my God, I’m going to be homeless, I’m going to fail, no one’s going to love me, I’m stuck in a van by the river.” Worst case scenarios to the extreme. Now, everything he does related to the paper brings him terror and so everything he does toward the paper gives him the immediate gratification of relieving some of the terror. Any action toward task completion is naturally reinforcing at this point. And the flow feels better and better because it’s getting you further and further away from the dragon. And then you turn the paper in, misspellings be damned, and you sleep the rest of the weekend. The anxiety level plummets down. The same graph can be used toward anger and task completion, too. We are using anxiety or anger as self-medication. David is not quick to throw medication at people but he does say that the second that anxiety and anger around the procrastination get in the way of your life and your relationships—can you see how a stimulant medication might help? A stimulant medication raises your ambient level of stimulation without you having to be anxious, angry or aroused. You need that stimulation to be able to work (like the allele cells and environment). Medication gives you a sense of urgency without a crisis. If you give ADHD medication to a neurotypical person, they will not perform better on the task but they will believe they did. They will write a five page paper and then they’ll turn it in and get an A (they would’ve gotten anyway). A person with ADHD will do significantly better on the task, believe they cheated because they used meds (and because of the knocks to their self esteem) but they also have a better evaluation of their work. The side effect is to give you a better ability to appraise their work more accurately, and it reinforces doing more work because it reinforces a sense of mastery. When someone doesn’t need ADHD medication, the medication will make transitions harder, it will make them more angry, more anxious over times and more rigid. With ADHD population, it helps with distress tolerance, transitions, and flexibility. We procrastinate when we need more medication. We procrastinate on packing for a trip, making lunches, making a list—the more boring a task, the more stimulation we need to do it. Gabe asks: where’s the balance of that? What if you accommodate yourself and never touch socks again? But you have to be an adult and do things you don’t want to sometimes. And David responds: Why not? Why not have only the same sock and not pair them at all? Or outsource that particular task. But, Gabe counters, what if he wants to learn the skill of folding laundry? How does he gain that skill? Medication is one option, but David asks more basically: how do you up your level of stimulation? Another way is to make it about time. Set a timer, don’t cheat, how many socks can you pair? Gamify it somehow, you can experience winning/losing. AJ names that this is something he did but didn’t have a name for. The reason he started folding his laundry is because his partner appreciated it, so it’s a win because it’s his partner’s love language. And once you’ve started you can always listen to one more song because there’s structure and progress. What if you say “ugh, I gotta clean my room” — what’s wrong with that statement is it’s too broad. You have to make it a smaller objective, like clearing everything off the counter. So with kids, day one, we’re going to clear the counter. Then we’re going to sift out the clothes. Now find all the cassette tapes, etc. Isabelle gets super excited about the KonMari (Marie Kondo’s organization method, see links below) because it’s literally this: taking everything of a category and putting it into piles, then deciding if each thing sparks joy. It’s simple, it’s structured, and it uses piles. David wants to make it clear that when the kid actually sweeps everything off the counter, and sees the big mess on the floor, they actually melt down, and it’s why he recommends it. That’s when you say to your child, “I know this is overwhelming and I’m here to help, I’m here with you. Now let’s get all the clothes.” Now you’re body doubling and you’re setting the tone for emotional regulation. It’s about sorting out the larger tasks and breaking them down. Another example is “tomorrow we’re going to leave”—making this broad statement when going on a trip. It doesn’t factor in the smaller tasks, all the stuff that’s packed into transitions gets left out. It seems so obvious but is so helpful to put language to. “Tonight I’m going to have dinner.” Gabe names that with their five year old, they found out they needed to draw pictures and draw it out the night before and give him predictability for the next day, but he never did it for himself. David names that he shouldn’t “should” all over himself, it’s about stretching these moments out. Do you ever take your morning routine and think about what the sequence or day will look like? Because now you have win probabilities and structure and a plan. It’s amazing how for someone with ADHD you can repeatedly have a 15 minute conversation about how someone is going to drink a cup of coffee—routines are hard to establish and we belittle ourselves for needing help with this, even though the details of the routine—when do you add the cream? When do you drink it? Do you pick your kid up first? If you pick your kid up, you’re taking care of them and will forget to have your coffee. Bobby describes it as putting his oxygen mask on first, that he needs to attend to his needs first because otherwise he’s not going to be a better person or parent. Isabelle describes how when she first got into body-based psychology, she was astounded that other people didn’t notice how it helped them remember to eat or go to the bathroom or do the basic care and maintenance of having a body. For her it was game changing to have a structure for how to check in on herself. When it comes to body based or other ways to create structure or accommodations, don’t just the accommodation, judge the accommodation’s effectiveness. For example, David worked with a kid who was going to give a big presentation and was feeling nervous, and he asked to put a marble in his sock. Knowing when you need body soothing or stimulation is great, knowing that chewing gum is mild stimulant and some people need to chew gum to tolerate stress. Pressure, like the pressure of a weighted blanket or a cat/dog in your lap, or a shower can be nice, but it’s good for soothing, not necessarily to help attend and it depends on what your goals are in the moment. There’s no quick fix and no one answer and there’s no way to make a hard thing easy except through exposure, the best way out is through. And the dilemma that we have is that there are a lot of people who are anxious around transitions and tough moments and they won’t push through. If you’re dealing with someone with ADHD, the big tip is to take the train all the way to the station. For example, with a fear of flying, people are actually not afraid of crashing, they’re afraid of falling. So he walks he walks through it with them, that once they crash, they’re dead…and the fear/panic is over. There is a time without it. Validate vulnerabilities—always tell people: it IS hard (because it is). Gabe asks about body doubling, whether you have to be modeling the behavior you want to see, hoping that at some point it’ll rub off, like through osmosis. David describes this is not always the case, that sometimes too much of the burden falls on the body doubler and you don’t want to always be setting them up for dependency: for example, if a kid struggles with doing schoolwork at home might need school-based accommodations (rather than putting more load on the home). Something he sees that’s game changing for kids with ADHD: no homework. Or make the kid stay an hour after school to finish their homework in that time. When’s the last time you had homework on your job? Or 6 separate jobs to do (like kids do when they have six different classes each assigning homework). Gabe wonders if there’s a specific type of ADHD med that works better for different types of ADHD—and in general, David’s seen them all work and not work. He does point out that when someone has more anxiety predominant, anxiety meds can help because the anxiety is a distraction; for others who are more impulsive/hyperactive type, they will notice that removing the anxiety makes it so they have lost the needed stimulation. In terms of ADHD being underdiagnosed or untreated, David believes it is severely underdiagnosed, often more so in marginalized communities and among people of color where systemic racism means the same behaviors are called “Oppositional Defiant” instead of ADHD. Are there people taking meds that don’t need them? Yes. Are there people who need the meds who are taking the meds? Yes. Are there people who need the meds who are not taking the meds? Yes. It’s all a big mess. Something David thinks (as a nondoctor/nonprescriber) that we overuse extended release medication that works for eight hours when perhaps you just need help going to the grocery store and folding your laundry—it’s like carpetbombing an outhouse. He’d love to see kids given medication with more psychoeducation so they get the metacognition aspect of it. It’s like there are no jobs where you need to concentrate for 15 hours straight, except maybe air traffic controllers, who use a lot of caffeine and drugs, but that’s a whole other podcast. And with that, David’s All About ADHD Lecture series comes to a close! Don’t worry, more lecture-type series are to come.
Marie Kondo's book The Life Changing Magic of Tidying Up and the KonMari method of organization
DAVID’S DEFINITIONS
Body Doubling: Someone else in the same room or within view of the person who is trying to get a task done—the other person doing the task creates the illusion of structure. In essence, a buddy is sits with you as you work on something (could be doing a task, or just quietly there, maybe giving you cues or reminders). In reference to in films, this term is used to describe a body double, or a stand in for lead actors in certain shots. Here are some basic ideas.
Metacognition: Thinking about thinking. Understanding and awareness of why you do the things you do. When you reach this point with any behavior, you’re more than halfway there.
Tips for accommodations:
Where does the behavior NOT happen?
Get clues about the environment.
Figure out what works for you.
Embrace it. Radically accept it.
Throw out what doesn’t work for you.
Don’t look at it as a failure.
If you’re procrastinating, you’re trying to increase your stimulation level:
What can you substitute that self-medicating anger, anxiety, or arousal with? Could be medication, could be something else that ups the anty.
Ways to increase stimulation include:
Time pressure (set a timer, don’t cheat)
Gamify it (set up a win/lose condition)
More sensation (depends on the person, could be music, a weighted blanket, a marble in your shoe)
How to tell what to outsource: you can tell someone what to do, but you can’t tell them how to do it.
What do you want done in a specific way?
This goes both ways: how to give instructions to someone with ADHD (see above).
Practice asking for time or for less when someone is giving you a big list or keeps talking
"I need one thing!” when getting distracted by inputs
Don’t give instructions to do things a dead person could do.
eg. Sit still, stay quiet, don’t move, don’t touch, wait five minutes, etc.
Instead, think of a specific thing that is active to do in that time/moment.
Collaboration is a key accommodation, but dependency fosters aggression.
Ask for the assist you need, but don't make it an expectation, you are still accountable for getting that thing done
"Can you make the kids' lunches for tomorrow?" instead of expecting the kids lunches are always going to get made
When asking for accommodations
Remember, folx with ADHD are often more reluctant to ask because we hear “no" so much, so it does involve practice and tolerating the distress of hearing a “no”
DARE (taken from DBT’s Dear Man technique)
D=Describe the dilemma
(e.g. “I really want to ask for a raise because I think I deserve one but I don't know how to do it.")
A=Ask
(e.g. “I would really like a raise.”)
R=Reinforce the other person, no matter what they say
(e.g. “Thank you for telling me no, I appreciate your honesty and being up front with me.”)
E=Empathize with the other person, remember they’re human and negotiate closer to what you want
(e.g. “I hear you, when's a good time to come back to this conversation?”)
When stating tasks or making goals, be as specific as possible, break things down into smaller steps, and consider visualizing or writing them out in pictures or words—this sets up structure.
Broad statements like “I have to make dinner” or “we have to leave for our vacation tomorrow” don’t work. Ideas like “I need to cut potatoes for dinner” or “first, we have to gather our clothes to pack” do.
If you’re anxious, take the train all the way to the station
Follow through the line of thinking, learn what you’re really afraid of and that it will end or have an end point
Validate that it’s hard (because it is). There is no quick fix, and there is no way out of something except through—you have to have exposure to the thing to develop your ability to tolerate your frustration about doing the thing.
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Cover Art by: Sol Vázquez
Technical Support by: Bobby Richards