All About ADHD - Part X

Something Shiny: ADHD!

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 exposur...