Tips and Tricks for Adults
Peter Harvey, Nathan’s father, goes to see you for his regular appointment. Now that his medication has been adjusted, he would like some advice on better ways to deal with the residual symptoms of ADHD. He asks for your advice. What strategies are effective for adults with ADHD? In cases where access to specialized resources is more limited, how can you guide and support your patient?
Even though the new DSM-51 has improved screening for adult ADHD, the health and social services system is not yet adapted to help adults who consult for ADHD and does not offer timely access to specific treatments, especially non-pharmacological ones, such as cognitive-behavioural therapy (CBT).
Dr. Nicolas Julien, psychologist, practises at Clinique Focus, affiliated with the Centre Médical l’Hêtrière in Saint-Augustin-de-Desmaures. M. Jean-François Giguère, neuropsychologist also practises at Clinique Focus and at the Institut en santé mentale de Québec. Dr. Annick Vincent, psychiatrist, practises at the same clinic.
You tell Peter that several strategies have proven effective as an adjunct to drug therapy for improving the functioning of adults with ADHD. These include time management, space management, task management and emotional management. Some psychotherapy models have been published in the form of guidebooks (in either individual2-5 or group6 settings). Popular self-help books also deal with this topic.7,8 Dr. Ramsay and Dr. Rostain propose strategies allowing clinicians to integrate these approaches with drug therapy.9 During the assessment process, you had already given Peter a pamphlet listing resources available to help him (readings and websites, contact information for an ADHD support group, the CLSC, psychologists, occupational therapists, and ADHD coaches in private practice). Thinking that he could handle this on his own, Peter threw it away.
Changing habits or attitudes is never an easy thing to do. This is where “motivation to change” comes into play. According to the stages outlined by Prochaska and DiClemente and presented in Table 1,10 Peter is in the contemplation stage: he recognizes or is aware that he needs help but is ambivalent, analyzing his possible options for the time being.
Targeting specific objectives helps choose strategies. This article proposes a selection of tools that can help adults with ADHD in this process. Some situations require specialist follow-up. Specific psychological treatment can help people to identify and question their negative thought bias and to work on motivational aspects. Occupational therapists, educators or trained coaches can also work with them to set up and apply effective daily routines.
The support documents identified by pictograms can be found in the Tips section at and . Readers using the online version of Le Médecin du Québec can access the documents mentioned in this article by clicking on the different icons in the Toolbox 1 section.
Specific psychological counselling can lead people to question their thought patterns and to work on motivational aspects. Occupational therapists or educators can also take part in setting up daily routines.
Psychoeducation is a major but underestimated step in the therapeutic process. When you simply give patients a pamphlet, you might have the impression of having done your job. However, it is important to follow up with them to see if they have read and used the information in it.
See Icon 1 in Toolbox 1: CADDRA: General ADHD Information and Resources.
Peter is starting evening classes. ADHD can lead to difficulties in school (see the article “ADHD: Truths and Misconceptions”). You inform him about possible accommodations, such as:
In Québec, support programs and grants for students with disabilities help cover the costs of certain accommodations and can be invaluable to the students. Family physicians play a vital role in getting these measures.
The decision to implement adaptive measures depends more on functional impairments than on the presence or absence of a disorder and must be individually tailored to the effects on school functioning. These measures should therefore not be automatically applied for everyone with a dysphasia, a learning disability (e.g., dyslexia, dysorthographia) or ADHD. If it is possible and the tools readily accessible, a trial period can help support their use. These measures are determined by the school administration for younger students and by the adaptive services teams for college and university students. A neuropsychological assessment can be an asset but is not essential for choosing the necessary type of accommodation and should therefore not be required by the teaching staff. In Québec, support programs and grants for students with disabilities may help cover the costs of certain measures and can be invaluable to these students. Physicians play a key role in helping students receive these measures, given that physicians are some of the professionals authorized to certify that ADHD is hindering student learning on the financial assistance application form (Application for Financial Assistance – Loans and Bursaries Program).
">See Icon 5 in Toolbox 1: ADHD and High School Accommodations
Peter is often late or at the last minute. Time eludes him; his to-do list is getting longer and longer, and he cannot find the time . . . to manage his time ! Although many people view time management and daily routines as utterly useless and boring, both are major components in ADHD treatment.
Young adults are particularly prone to poor time management. They feel overwhelmed by their growing number of obligations, combined with a decrease in external support (e.g., less parental supervision). At a certain point in life, adults seek medical advice to reduce the effects of ADHD because they are no longer able to function despite the strategies they are using. The solution: finding a new way to work! Here are a few tips:
Ten-minute strategy: When you feel the urge to postpone a task, decide to do it for just ten minutes (regardless of how much you accomplish during that time). Starting a task without feeling obliged to achieve immediate results can help you put your ideas in order, attend to the task and lower your anxiety.
See Icon 2 in Toolbox 1: Time Management to Boost Your Productivity
Peter is late. He had misplaced his keys . . . again! Besides managing their time better, adults can benefit from organizing their space to reduce the effects of ADHD. Many get discouraged because they don’t know where to start or are unable to stick to their good intentions. Here are a few winning strategies:
See Icon 3 in Toolbox 1: Conquering Space
Peter would like to improve his financial situation. Impulse buying and forgetting to pay bills are never winning solutions. Poor financial management can negatively impact your personal life and relationships, especially with your romantic partner.
See Icon 4 in Toolbox 1: Practical Financial Management Tips
Peter tends to quickly lose control and fly into rages. His impulsivity stops him from taking a step back to analyze the situation. He reacts rather than acts. The hyperactivity associated with ADHD gives the feeling of riding an emotional roller-coaster and has significant impacts on relationships. People regret their impulsive overreactions and fear them so much that they avoid all risky situations and isolate themselves.
When you are about to erupt . . . take time out to relax and to change your ideas (Toolbox 3).
See Icon 8 in Toolbox 1: ADHD and Leading a Balanced Life
Once patients have better control over their emotional outbursts, it is time to initiate an introspective process to deal with their automatic negative thoughts. Becoming aware of cognitive distortions allows people to undertake a cognitive restructuring exercise. This process is designed to lead them to intercept their automatic thoughts and to raise reasonable doubts about them (Table 2).
The chart developed by Ramsay and Rostain,9 which identifies common cognitive distortions in adults with ADHD, helps initiate a cognitive approach. A summary of the four-step cognitive restructuring exercise, along with examples, can be found in the document “Cognitive Restructuring 101” (see Icon VI in Toolbox 1). This type of technique is effective for managing not only anxiety but depression as well.11
Using Ramsay and Rostain’s cognitive distortion chart,9 Peter realized that he has been prone to magical thinking since he received his ADHD diagnosis and his doctor prescribed medication for it. Table 2 shows the cognitive restructuring exercise he performed following this realization.
Now it’s time to walk the walk! It’s not enough to talk about it. You have to do something about it! The exposure technique helps to gradually tame your negative emotions (e.g., performance anxiety) that generally provoke avoidance behaviour (e.g., ten-minute strategy, see the section “Practical Time Management Tips”).
Peter has been burning the candle at both ends. He is tired because of his unbalanced lifestyle. Knowing that ADHD can prevent people from adopting and maintaining a healthy lifestyle, you explain that poor nutrition, insufficient sleep and a sedentary lifestyle exacerbate the symptoms. Here are a few tips to break this vicious circle:
Additional Information on Academic Success
In the Québec public elementary and secondary school system, applications for accommodations are submitted by the school. Technical equipment is made available to the schools and loaned to students with special needs. Students are usually referred to school administrators who will determine their needs in an individualized intervention plan (IIP). Private schools and the public post-secondary system (CEGEPS and universities) have individualized programs and grant technical equipment directly to students.
Choosing someone close to you to confide in can improve how each of you understands ADHD. Some people become excellent daily life counsellors and coaches. Support groups help you get informed, receive support and break your isolation. In Québec, find your nearest support group (e.g., PANDA at ) and, for the rest of Canada, visit CADDAC ().
Nathan’s family and you have come a long way. Together, you have overcome the barriers associated with ADHD and you can now see positive results from this process. Your patients have gained benefits, and you have gained a sense of having been able to make a difference. And look, you’re ready to do it again! Didn’t we tell you: screening and treating ADHD can be addictive! //
French Version: Received: January 27, 2013 Accepted:April 17, 2013
Translated in English: September, 2014
Dr. Nicolas Julien and Jean-François Giguère have no conflicts of interest to declare. Dr. Annick Vincent is a speaker and an advisory committee member for Biovail, Lundbeck, Bristol Myers Squibb, Lilly, Purdue, Janssen and Shire. She received grants from Purdue, Shire and Janssen from 2011 to 2013.