ADHD, Addiction, & Mental Health Interventions Part 2

Foreign. I'd like to welcome everybody Today's presentation on ADHD, addiction and mental health interventions. I am your host, Dr. Donnelly Snipes. In this presentation, which grants you is an hour, so, you know, just kind of brace yourselves. We're going to explore physical, affective, cognitive, environmental and relational interventions that can benefit people with ADHD and comorbid conditions and identify common treatment issues and specifically how to address those. ADHD is often a lifelong condition and predisposes people to the development of mood and addictive disorders. Mood disorders are associated with worse ADHD symptoms. Obviously, if we can prevent mood disorders, that's good, but if we're working with someone with comorbid conditions, we want to recognize that that is likely going to intensify their ADHD symptoms or probably because of additional dysfunction in that dopamine and norepinephrine system. Remember, as serotonin levels change, so do dopamine and norepinephrine availability. As such, early intervention and a lifespan approach needs to be considered. Obviously, if we intervene early when the youth is showing signs of adhd, hopefully we can prevent the development of mood disorders. However, throughout the lifesp, since we know in about 70% of people they continue to have at least some symptoms of ADHD throughout their life, it's important to continue to address that and recognize that in a integrative behavioral health approach to treatment, to prevent them from developing depression or anxiety later in life, or if they do happen to have comorbid issues, prevent, prevent those issues from worsening, also helping them recognize that as their other issues. We'll just use mood disorders, for example, as those mood disorders are exacerbated for whatever reason, like too much stress going on, it will likely lead to an increase in their ADHD symptoms. This will help them understand what they need to do and recognize that, okay, I'm feeling, I starting to feel anxious, I'm starting to feel depressed, which means I need to take additional steps to intervene and prevent my ADHD symptoms from, you know, starting to cause me problem, more problems or problems in my life. So what can we do? Remember on Tuesday, we talked a lot about, you know, the underlying causes of add, adhd, mood disorders, and arrived at the conclusion, if you will, or the summation that ADHD and most mood disorders and addictive disorders have roots in the functioning of norepinephrine, dopamine, and the prefrontal cortex. Now, a lot of our mood disorders also have some roots in serotonin signaling. However, people who are who have ADHD, who take SSRIs often don't see much symptom relief because the impact on the dopamine and norepinephrine systems when they, when SSRIs are taken is not significant enough to attenuate the ADHD symptoms. Okay, we are not prescribers, so I'm not going to focus a lot on medications here. What we're going to talk about is how can we naturally, basically naturally increase those levels of dopamine and norepinephrine and serotonin so the person's brain can function more effectively getting adequate quality sleep. Remember on Tuesday we talked about the fact that even when you control for mood disorders, the level of exhaustion or sleep deprivation correlated with the severity of ADHD symptoms. So it's important to, to get adequate quality sleep for adhd. We know this. We also know that for anxiety and depression, those things are also impacted by inadequate quality sleep. The ability to focus, foggy brain lethargy, and even some apathy. And reduced serotonin can be caused by exhaustion, partly because when people are exhausted, their HPA axis cranks up and it makes your calming serotonin and your, your happy chemicals, your cool chemicals less available. So getting adequate quality sleep, this is important. But if you look at the average middle schooler, teenager, collegiate person, or even adult, how many of those people actually get seven to nine hours of quality sleep nearly every night? I dare say it's in the minority. I'm one of those people. I've said hundreds of times before, sleep is one thing that I don't play with. You know, I get my sleep every night because I know that significantly impacts my ability to focus. But a lot of people, my children included, are really bad about taking this one step that is so essential to reducing cortisol levels, reducing stress levels, improving mood and improving focus, as well as preventing and mitigating symptoms of mood disorders and adhd. We want to regulate our circadian rhythms to support normal cortisol levels and HPA axis functioning. When we wake up in the morning, our cortisol levels are supposed to be at their highest and they decrease throughout the day until it's time to go to bed when they're at their lowest. Your body tunes into this partly based on light. And so sleep sleep is important. It's important to go to sleep about the same time every night, get up about the same time most days. But it's also important to regulate your circadian rhythms through exposure to light and ideally natural light. And it doesn't have to be a whole lot. It doesn't have to be all the time. They've done some studies with ICU nurses and NICU nurses who, you know, they're in the dark a lot of the time. They try to keep it quiet and dark so the patients can rest. And they found that those people, if they would periodically go outside throughout the day and expose their brain to that bright daylight for even five to 10 minutes, three times, it had a significant impact on regulating their cortisol levels and their cortisol cycles and, and helping them feel like they were awake when they were supposed to be awake, and so they were ready to go to sleep at night. Take medication as prescribed. Not everybody who has mood disorders is necessarily going to be on medication, but from what I've read, the majority of people with ADHD are on medication and may have to take medication throughout their lives. Not everybody, but some people do. A lot of people, when they get to adulthood and that prefrontal cortex is actually fully developed, remember that's age 24. When that's fully developed, they have overcome some of the biological hurdles, but they've also developed coping skills to deal with their symptoms. So they may not need medication as much as often or at all. But if it is prescribed, take it as prescribed. Eat healthfully to support dopamine, serotonin and norepinephrine production and brain glucose. If you watch that video from Tuesday's lecture from the. Oh, I can't remember his name. The doctor that did the video about Asperger's, ADHD and giftedness, he talked about the fact that the brain is one of the biggest consumers of glucose. A lot of children who have giftedness or have ADHD because they are feeling like they are moving a lot, because they're agitated, irritable, whatever word you want to use, because they actually do move a lot more, they burn through more glucose. And it's important for them and their behavioral issues to make sure that their blood glucose stays stable throughout the day. Same thing is true as an adult, and he was talking about children. But think about if you've been in a conference and you know, you've really been paying attention in the conference and at the end of the day, or maybe you see clients and you've had seven back to back or something, you've really been honing in and at the end of the day you, you just feel like you've run a marathon, you're exhausted and you're like, I, I sat all day long, I hardly moved. Why am I tired? Well, that's why your brain has burned through a ton of glucose. So it's important to recognize this and make sure that people are consulting with a dietitian or a nutritionist to develop a eating plan that will support not only the development of neurotransmitters, which is, you know, pretty much normal nutrition. That's nothing super different there. But also so they're eating frequently enough and eating the types of meals that support sustained blood sugar instead of having these highs and lows. Obviously, if the person also has concurrent diabetes, that's a whole other issue to deal with and a whole other reason that we need to pay attention to blood glucose. Exercise increases dopamine and serotonin. We know that people with ADHD tend to be more restless. We know that people with mood disorders often have low levels of dopamine. We know that people with addictive disorders have dysfunction in their dopamine system. So by exercising, we're doing a lot of things. We're fine. It's providing constructive outlets for excess energy, and it's increasing dopamine and serotonin levels in the brain. And if you exercise hard enough, sometimes it increases endogenous opioids. Another thing with low intensity exercise is it reduces cortisol levels. It reduces that HPA axis. And when I say low intensity, I mean, you know, walking around the block at an average pace, not really hoofing it at all, but that is keeping you at a level. They found that 40 to 50% of your target heart rate training zone actually reduces cortisol levels, which is good for people who have high cortisol because they have high anxiety. Sunlight. You know, I talked about bright light for regulating those circadian rhythms. We talked about getting adequate sleep. But sunlight, like natural Sunlight, increases natural D3, which increases dopamine availability, which has been connected with improvements in mood as well as reductions in cravings and reductions in symptoms of ADD adhd. Like I've said before, when we're talking about sunlight and D3, we're not talking about doing what we did in the 80s and sunbathing until you were a crispy critter. We are talking about 10 to 15 minutes a day day, which most people get during the summer when they're walking to their car in the morning, when they're driving, you know, because you still get some sunlight in through the window when they're. And when they're walking to. Into the store, when they're walking into work, you probably spend 10 to 15 minutes outside every day and don't even think about it. During the winter, when the Days are shorter and you're going to sleep and it's dark outside and you're leaving work and it's dark outside. And it's a little bit more important to actually make a concerted effort to get outside for 10 to 15 minutes. And you don't even have to stand like right in the middle of the bright sun. But it's helpful if you can be in like dappled sunlight. So your brain, your, so your skin, which is a, basically a large endocrine organ, can help regulate some of your hormones and increase those vitamin D levels. Get a physical and blood work. I say this with every single diagnosis because every single diagnosis has the possibility of having underlying physiological causes or contributors. T3 and T4, those are your thyroid hormones. When those are out of, out of whack, they can contribute to depression, they can contribute to anxiety. And it's also important to recognize, you know, if you have, for example, high thyroid, it may contribute to being fidgety and restless. Gonadal hormones, your estrogen, progesterone, testosterone, those are related to the availability of dopamine, norepinephrine and serotonin. We want to make sure that imbalances in the gonadal hormones are not contributing to imbalances in your neurotransmitters. And then obviously blood work can also check for vitamin D levels to tell you whether you're getting enough sunlight. And if not, sometimes doctors recommend over the counter vitamin D supplements. Those are not nearly as readily absorbed and used by the body. Obviously, that's something for people to discuss with their physician. Get vision and hearing screenings. If people who have ADHD or who have symptoms of ADHD may also be restless, especially like in school, and not be able to sit still because they're having difficulty understanding what the teacher is saying or seeing what's being written up on the board or seeing what they're reading in their book. Now, that doesn't necessarily preclude the ADHD diagnosis, but we want to look at some of the contributors or some of the things that exacerbate ADHD and ADD symptoms. And obviously, since people with ADHD and ADD have a significantly higher increase risk of developing addictive behaviors, it's important to seek treatment. And when I say behaviors, I don't just mean drinking substance, alcohol or using illicit drugs. I am also talking about any other thrill producing, dopamine surging behavior, including gambling, sex addiction, you know, anything that can fall under the rubric of maybe a compulsive behavior. We haven't put a Lot of things in the behavioral addictions category in the DSM Internet gaming disorder is another one that is highly correlated with ADD and adhd. When people are regularly engaging aging in addictive behaviors, hence the term addictive, it causes the brain, just like stress causes the brain to adapt and you develop hypocortisolism. When the brain is regularly being exposed to surges tidal waves of dopamine, it figures out that, you know what? This, we can't do this. This is too much. This is toxic. So it starts shutting some of those floodgates, if you will, and it keeps them shut. So then in order to feel, quote, normal for that person, whatever that is, they need to do more in order to, you know, get that feeling of normality. Not even a rush anymore. It's just to feel normal. And this is the tolerance that we talk about in addiction. But it is unfortunately a common comorbid condition with ADHD since both of them involve dysfunctional in that dopamine system affectively. People with comorbid anxiety have significantly poorer responses to stimulant medications than those those without anxiety. I thought that was a really interesting study. So let's think about this. When people have anxiety, their HPA axis is revved, and they are dumping cortisol. They are dumping norepinephrine like nobody's business, which is a stimulant. They are dumping glutath, glutamate, like, like nobody's business. And glutamate is your main excitatory neurochemical. So they're actually already flooding their system with stimulants when they. When they're anxious. And it. This stimulant medication probably isn't able to do the same thing because the brain is focused. When that HPA axis is activated, when somebody's anxious, the brain goes into tunnel vision. We know when somebody is in that fight or flea mode, they're in tunnel vision, which, you know, it's trying to fight or flee. It's not worried about focusing on doing schoolwork. It's not worried about focusing on cooking or talking with your significant other. It is naturally ramped up to deal with anxiety. So when we add a stimulant, we're just increasing that stimulation and maybe intensifying that HPA axis reaction. So that's my hypothesis for why the stimulants may not be as effective for people who have active comorbid anxiety. Once the anxiety is attenuated, the stimulants seem to work very well. But it's important to. To recognize that There is a interaction there. People with ADHD tend to regularly emotionally dysregulate and have a low frustration tolerance because of the impulsivity, the attention deficit that. Well, impulsivity. When people are kept from attaining something they want or they're not able to do something, they get very frustrated very easily and they go into a dysregulated state. We want to help people enhance their distress tolerance skills. Now think about when you're working with somebody with ADHD who is often struggling with issues of restlessness and boredom and having difficulty sitting still. You know, we're thinking about some of these things. If, if the person has those hyperactivity characteristics, there are some distress tolerance interventions that may not be super helpful for them because it makes them feel like they are having to sit still when they feel like they want to crawl out of their skin. So we do want to be respectful and cognizant of the fact that we need to tailor some of these dysregulation tools. Breathing can help with emotional dysregulation, especially with the addiction with the person with ADD inattentive type, as opposed to the hyperactive disorder. Breathing. Breathe in for four, hold for four, out for four, helps slow that heart rate, slow the respiration, and trigger the rest and digest response. That's not going to work for everybody, but it can be helpful if somebody feels really frustrated. I remember when my son was learning, trying to learn how to tie his shoes. He would get so frustrated, as soon as he couldn't figure out what to do. He would just. He'd rip his shoe off and he'd throw it across the room, and he'd tell me he wanted his Velcro shoes back. And I'm like, no, we're not gonna do Velcro shoes your entire life. But recognizing that he was very frustrated at that point. And for him, breathing worked but not sitting down and breathing. We would walk, you know, I would. I would take his little hand and I'd say, okay, let's go walk outside for a second. And we'd go out onto the porch, since he obviously didn't have his shoes on. And we would walk. And I would encourage him to breathe in and hold and breathe out so he could get what he called recombobulated. Encourage people who have difficulty with frustration tolerance or dysregulation to identify activities that they can do to sublimate, as Freud would say, their frustration, to sublimate that energy and use it for something productive. Instead of putting their fists through the wall or yelling or throwing something or whatever it is they do. How can they use that energy? Which again can be go out on a walk for a minute. When I worked at the drug treatment center in residential, a lot of people, early recovery, just out of detox, a lot of really raw nerves. And when people would start to get into disagreements, we would occasionally have to separate them and one clinician would take somebody out to walk around the outside and another clinician would take, take the other person to walk around the cafeteria or something. But a lot of times when people are revved up, when they are in that fight or flight phase, Think about it. Fight or flight, that doesn't say sit down. You know, sitting down is contrary to what the brain wants to do at that point. So gently helping them move out of that fight or flight place is really helpful. People with ADHD and ADD can benefit by talking it out. Sometimes they just need to articulate what's going on with them. And sometimes sensations can help. Whether it is physical sensations like doing sit ups or push ups in order to sublimate that energy or splashing water on their face, you know, it gives them something to do for a second to help them get back into their wise mind. When there is an episode of dysregulation or frustration. Encourage them to examine their underlying thoughts or cognitions related to that situation. What was it about this that caused you so much frustration, that caused you so much anger? And you know, what messages did did you get that you for example, had to be able to succeed at tying your shoes on the first try? You know, it was important for me to, with, with my son to help him understand, you know, it takes people a little while to learn how to tie their shoes. It's not just something you wake up and can magically do. So normalizing that for them, but helping them examine, using basic ABCs, looking at those automatic beliefs that the person has in order to help them address their emotional response. Have people increase positive and I call them dopamine priming activities. Do things that are pleasurable that they want to do again because that increases dopamine. Address trauma or other issues contributing to anxiety or depression and identify cognitive themes like rejection, failure or getting in trouble. Those are common themes in add. A lot of people with ADD ADHD have difficulty with feeling accepted because they have that impulsivity. They tend to blurt, have difficulty taking turns, can be disorganized or forgetful, and that can take a real toll on relationships regardless of the age of the person. Failure is another big issue for people With ADD adhd not because they're not capable, but if they don't have the skills and tools to deal with their symptoms, that disorganization and impulsivity can cause them to potentially not do an assignment as well as they could. A lot of people with ADD have difficulty following through on assignments. They get bored halfway through and they just, just don't do it. And that contributes to failure in for work products, for school, for tests. You know, we can see how that can be a, an issue and, and getting in trouble. People with ADD inattentive type may get in trouble for daydreaming in class or not paying attention in a work meeting. With ADHD they may get in trouble for because they're not able to sit still or they're too impulsive. All of these are, are common themes in ADHD ADD and they can contribute to the development of depression, anxiety and addiction, especially addiction in that's used for well self medication but also for numbing the pain of rejection or failure. We also want to address emotional reasoning and anticipatory anxiety in people with ADD adhd. If they are thinking, you know, if I, when I go to this meeting I'm going to have to sit still for three hours. I don't know if I can do that. They can work themselves up into an anxious state and we know that as anxiety goes up, ADHD symptoms go up and they can actually be intensifying their challenges with sitting still through the conference or through the meeting. We do want to talk with them about, okay, what have been your experiences in sitting in a meeting or being on an airplane for two hours? Whatever it is, what are you expecting to happen and how likely is it to happen and what can you do to prevent your worst fears, so to speak? You know, what is it you can do on that two hour plane, plane ride in order to keep yourself from being fidgety and you know, feeling like you're going to crawl out of your skin. Cognitively, we want to enhance people's self esteem and self efficacy regardless of their diagnosis. What am I good at? And help them learn how to set and achieve smart goals. Remember, specific, measurable, achievable, related and time limited. So we want to make sure that we help people with ADHD learn how to set goals because again, they are very competent and very bright people. You know, ADHD has nothing to do with intellect. We, we need to help them understand that and recognize that okay, we, this person over here may be able to set a larger goal like they may be, may be Able to set a goal of reading an entire chapter or studying for an hour. And that might not work for you. So let's look at setting a smart goal that is useful and, and that works for you as a person. And a lot of times when dealing with add, adhd, people have to, you know, set smaller goals, smaller time limits so they can achieve them. They can get the reward which primes that dopamine and be successful. Encourage people to learn about their learning style. It's really hard to pay attention when you are being taught in a way that is not akin to your learning style. Even if you don't have ADD or adhd, it's important for people to know their learning style so they can put themselves in a situation that is as accommodative. Is that a word as possible. So learning styles auditory, which is what you're doing. Well, if you're listening to this, it's what you're doing. Now. Visual is reading. You know, those are the people who want to read the PowerPoint or see the, see the show notes and be done with it. They don't want to listen to the whole hour. And kinesthetic, those are people who need to manipulate information in order to best learn it. Now, briefly, auditory. People who learn better in an auditory setting who are having to learn through a book can record those notes or record those LE chapters and then listen to them later. People who are visual can take notes. People who are kinesthetic do really well if they create their own quizzes or do something to manipulate the material and relate it to something that they know that helps them. You don't have kinesthetic doesn't necessarily mean actually using your hands. It can mean manipulating the material in your mind. Preferably use all three learning styles. But most of us have one that we prefer, one that's secondary and then one that's tertiary. Helping people learn how they learn so they are not compounded by being in, in an environment that is not with their, with their preferences. The other type characteristic of learning that I'll talk about here is active versus reflective. And this can be really difficult for people with adhd. Especially active learners tend to be extroverts. If you think mbti, they tend to be extroverts. They tend to think while they talk. So it's really hard for them to be quiet. And, and that's one of those really interesting things. When you start working in classrooms a lot, you find there are some people that really want to talk it out. They want to be in small groups they want to engage in discussion and that's great. They, they think and talk at the same time. And then there are your reflective learners who maybe appear more as the inattentive type or. And they tend to be more introverted on the Myers Briggs that need time. They take in all of the information, they absorb it like a sponge and then they need a couple of minutes of quiet time to kind of put it all together and have that aha, light bulb moment. One way is not any better than the other. But for people who do better talking it out, thinking and talking, they're active learners. Being in a situation like this where you're not able to actively engage with somebody in a discussion can be really challenging. And we want to help them figure out, you know, how can you best make whatever your situation is work for you? Encourage people with ADD ADHD to get screened for dyslexia. There is a very high correlation between ADHD and dyslexia, which again makes it harder for people to pay attention. People with dyslexia. My daughter has dyslexia and she would get so frustrated when she was reading because, you know, the words would jumble on her. So she that low frustration tolerance. If you have somebody with 88 ADD ADHD, that can kick in. Difficulty focusing and paying attention because of the dyslexia, not even necessarily because of the ADD adhd. Dyslexia is a huge issue to get screened for. Encourage people with ADHD to prioritize. A lot of times they end up with multiple projects that are halfway done and nothing ever gets finished. And that's often works against their self esteem because they feel like they can't finish anything. They fail at everything they try. So it's important to help them hone it in a little bit. Let's focus on, you know, what are the five most important things for you to work on to move towards a rich and meaningful life. Encourage them to chunk it. And when I say chunk it, I mean do things in small chunks, 10 minutes, 15 minutes, and then maybe switch to another subject or get up and walk around the room and then sit back down again. So they don't dread doing their homework, so they don't dread doing their, their progress notes. If, you know, if you're working with a colleague who has ADHD, 10, 15 minutes is often a good chunk. And have them relate what they're doing to something that they're interested in. A lot of people with ADD adhd, even though we think of them as being inattentive, a lot of people with adhd, when they are focused on something that really captures their interest, they are enthralled with, they will go into this zone and they will focus for a long period of time. So if you can encourage them to relate whatever they're learning or doing or working on to something that they are interested in that can help increase their attention. And remember, attention and perseveration are related to dopamine and norepinephrine. Help people create solutions, lists that and keep it with them that provide options in response to distress and impulsivity. When I am feeling upset, I can and have them have a list of 10 things that they can do and 10 things that they can think about because sometimes they can't get up and do anything. So encouraging them to think about those things. Keep it with them. When they are dysregulated, they are not going to be thinking about what their options are. They're in their emotional mind. That's when we tend to be more impulsive. So it's important for them to have it with them and easily accessible. If they get dysregulated and they have it with them and they don't remember to use it, that's okay. Talk about, okay, how can you remember to use it the next time? Plan ahead. Adults with ADHD often have difficulty drawing on past experiences to guide their actions. They may not be good at recognizing the subtle aspects of problems and the various tools that might solve them. They're just kind of. Everything kind of blends together for them. Encourage them to slow down a little bit and picture a TV or, well, TV, everybody still has TVs. And imagine the last time you were in a situation like this playing on the TV like a movie. So you're seeing, you know, the last time you went to a conference or the last time you had to fly on a plane or had to sit through a class. See yourself doing that. See that situation playing out on the imaginary tv. What did you learn from that experience? Maybe you can look back at that airline flight and go, okay, well I learned that I need to bring a whole lot more than one book with me if I'm going to be on a plane for two hours. What did you learn from that experience and what are some of the details that made it similar and different to this current situation? Encourage them to really delve into those prior experiences, to pull out and learn from every experience to improve the next time. Encourage people to verbalize thoughts and reasoning when they're having a urge to act out instead of acting out physically. Encourage them to talk it out. And like I said earlier, sometimes it's easier for people to walk and talk at the same time when they are agitated. And in that fight orf flight mode, there is a school of thought called bioenergetics that talks about how when we're upset, our energy is coming up and we need to move our big muscles to reground ourselves. However you think about it, think about when you're upset. Do you really, if you're angry, if you're agitated and fight or flee, do you really want to sit down and sit still? Most of us don't. Most of us want to do something. They have found that training your brain with apps like Luminosity or Elevate can improve focus, memory and thought organization through practice and repetition. So they're actually studies that people can improve some of their focus and memory skills. Many people with ADHD forget the purpose of their task, so they're uninspired to finish them. They may need some prompts to keep moving toward their goal. I crocheted a blanket for my best friend many, many years ago. But crocheting a blanket takes a long time and it was important. You know, there's some days I'm looking at it over in the corner going, I don't really want to do that. But I kept remembering that I wanted to give it to him as a Christmas present. And, you know, so I had a time demand and it was important to me to, to get that done. So I needed to keep reminding myself, you know, why is it that I'm doing this again? To continue doing it. Encourage people to keep visual reminders up as needed to help them keep focus on, you know, why is it that I'm studying, you know, neurobiology or whatever they're studying for whatever class they're in. Why am I in this class? Remind them of the ultimate goal because I want to get into medical school and that that's really what my heart desires. That'll help prime that dopamine a little bit, have people imagine the positive consequences of doing something to again increase that dopamine. When we even envision, when we use guided imagery, when we think about the positive consequences, how awesome it's going to be when it's done. That actually does give us a little bit of a squirt of dopamine and norepinephrine. You can get apps that are designed to remind you to take your medication and put them on your phone to remind you each morning to visualize your day. So when people get up in the morning, they have an app on their phone that reminds them to take five minutes to visualize everything that's going to happen that day, see what's going, see what they're going to do, envision it going well. And that also helps them remember, you know, oh, yeah, I have, you know, taekwondo after work tonight, so I need to remember to bring my, my dobok. My son would regularly forget things like that. Bless his heart. Imagine how great it will feel to get to your goal and add visual reminders. For my kids, when they were in martial arts and they were working towards their black belt, you know, seeing the black belt hanging up there on the, on the wall above the, the door in the dojang was always inspiration for them because they wanted it. Every time they saw it when they walked in, it was like, okay, I'm going to get that pretty soon. We can do the same thing with any disorder. But that's another way to again prime that dopamine. Because the brain says, oh, that's something I want. And dopamine is our, I want it neurochemical. Encourage people to increase their motivation. And again, we use that pacer framework. Physical motivation, how can doing this make me feel better? Physically have more energy? Affective motivation, how is it going to make me happier? Cognitive motivation, how does doing this make sense to help me achieve my goals? Environmental motivation, what things can you put in your environment that can serve as prompts to remind you to do it and why you're doing it to keep that inspiration going? And relational motivation, how is doing this, how is whatever I'm trying to do going to improve my relationships? And what supports do I have that can help get me through it? Environmentally encourage people to train themselves to become more organized. People who are anxious have difficulty focusing. People who are depressed often don't have the energy to care about focusing. And people with ADHD may have difficulty just focusing. People with addictions are often too focused on their addiction of choice to focus on other things. So it's important to help help folks, you know, regardless of their, their diagnosis, but if they have ADHD and or additional diagnoses to become more organized by using alarms and push notifications, even if it means they have something going off. I have, I'm, I'm a J on the, on the personality or on the temperament scale. So I like structure. So I have alarms that go off. Push notifications like every hour, every two hours. Write things down on your mobile device and set an alarm to check the notes each morning. So it throughout the day as you're thinking about things that you need to do the next day or need to bring with you. Make notes on your mobile device because most people don't let their mobile device get more than about two inches from them. And that push notification in the morning can also remind you to check those notes so you remember what's coming up that day. When you get any documents you need, scan them into the computer or take a, take a picture of them and save it to something like Google Photos so you have it if you need it later. Envision the steps of your day each morning and don't get over organized. Sometimes people can take it to the nth degree. I remember at the beginning of every school year back in the day when we had trapper keepers, I would have a trapper keeper and I would have a, you know, special folder for every single subject and I would have, you know, all these different and I was going to be organized that year and that usually lasted for about three weeks, maybe not even so. And then I would feel frustrated because I hadn't stayed organized. Encourage people to get organized to the extent that they need to, but do it in a way that they can actually adhere to. When I do laundry, for example, you know, I have drawers, you know, I have my sock drawer and I have my underwear drawer and I have, you know, different drawers and I'm not, I don't sort it out by, okay, here's where the white socks go and here's, you know, then I have a little cubby for the black socks and the gray socks. No, I ain't got time for that and I'm not going to keep up with that. So I'm just happy if like gets with like minimize distractions when you need to focus. That can mean having a private space using noise canceling headphones. It depends on the person, what they need to do. I shared with you on Tuesday when my son would say study when he was really young. We had to close the blinds when he was studying because the birds would attract his attention and he would just be immersed in them and two hours later I'd walk in and he hadn't made any forward progress. Ensure you feel and, and it's going back to that. It's important for caregivers to recognize that children with ADHD and ADD are not doing that on purpose. They're not being oppositional or disrespectful. It is an organization and a filtering thing that has neurological frontal cortex and neurochemical dopamine and norepinephrine roots. So it's not just something they can will away and force themselves to focus. Ensure you feel safe. This is at the root of, you know, wellness to begin with. If people don't feel safe, they are going to be more hypervigilant. They're going to be be scanning, they're going to be more attention, pay more attention to extraneous stimuli. People with ADHD already have difficulty filtering out extraneous stimuli. So you know, if you ramp that up some, it's going to make life even more difficult for them. So make sure that wherever they're at, they feel safe. Have them keep a toolkit or a rescue bag with them to help them deal with boredom and restlessness. And as children or as adults I mentioned Tuesday, I don't sit still very well and I need to do things to fidget, whether it's writing or playing with a, you know, a Scrabble app on my, on my phone or doing something. I am not one of those people who is very good at being Zen and just sitting still. And it's important for me when I go on long drives or the airport or wherever to take things with me so I can keep myself duly occupied. Caregivers and teachers need to facilitate success in places like car rides, restaurants, churches, going to the grocery store, or when visiting people like family by bringing that rescue kit to address visit fidgety behavior, restlessness and boredom. People with ADHD do not tolerate boredom well. So, you know, even if they're sitting still for a moment, if they start getting bored, they are going to probably start becoming more agitated and that may lead to more restlessness and impulsive behaviors. Facilitate success in schoolwork by working with the person to develop checklists and helping them to train themselves to pack and check the night before. Pack your backpack or your briefcase the night before. When you get syllabi at the beginning of the semester, put it into the calendar with push notifications so the person knows that with Sean, I have him do it a week ahead of time so he knows that, okay, next Friday I've got an exam in biology. Next Thursday I have a paper due. And then help them plan with with school kids. For example, science fair is on November 12th. And then ask, you know, the child, when do you think you need to start working on your project so you're ready for the Science Fair on November 12th. If you've had kids going through school there, I think most parents have had those nights where you get this little knock on your door and it's like, I forgot I Have this project due to, you know, tomorrow morning on third period, it's like, okay, so helping them, you know, push through that relationally. People with ADHD need to develop their interpersonal skills. And really, we're going to talk about working on blurting in a minute. Caregivers need to focus on the per. The child's strengths, not their mistakes. People with ADHD add, if they drift off, if they become impulsive or restless, they can learn from that. We want to help them learn from that. I'm not saying ignore it, but we also, most of the time, we want to focus on their strengths. So before you go into the restaurant, for example, instead of saying, now, don't let this be like last time when you got up and we're running around the restaurant, you want to start by saying, all right, we're getting ready to have a good dinner. And what do you think you're going to order? You know, what, what type of food do you think you're going to eat? And. And how. What is it that you're going to do? How are you going to behave or go through something positive? Helping the child envision what the positive is going to look like instead of bringing up the negative. If the child makes a mistake, okay. Or even if the adult makes a mistake, fine. You know, learn from those mistakes. Looking back at it, what could I have done differently to prevent that from happening? For caregivers, teachers and supervisors provide or help create to do lists. Now, a lot of supervisors are not going to be super excited about doing this, but it is one of those reasonable accommodations. Know what you need from other people and communicate that to them. If you're, you know, in a relationship with somebody and, you know, you tend to be disorganized or, you know, you tend to be forgetful. Now, ideally, put notifications in your phone, so you're going to have to have no problem with it, but let people know that you need advance notice or it would be helpful if you would call me 30 minutes ahead of time in order to make sure that I'm ready. One thing I encourage people to do is to practice saying maybe so they have time to think about whether to say yes or no too. Too many times. People with add, adhd, they're impulsive. They hear something, they get invited to go to the movies or do this or that, something that they want to do, and they just impulsively say yes without thinking, what else do I have to do? In order to provide them the ability to say something right away, to work with that impulsivity I encourage them to say maybe or let me think about it and then take a couple of minutes, think about it and, and figure out yes or no in terms of blurting. This can be a really big issue for people with add. Have them make a list of the inappropriate situations in which they are most likely to behave impulsively. And we. You can do it with your young child. You know, work, work on it together. Or if you're working with an adult, have them make the list themselves. When you're about to enter one of those situations, try one of the following things before you answer someone. Inhale slowly, exhale slowly, put on a thoughtful expression and say to yourself, well, let me think about that. When you're working with children, you know, obviously that's a lot for them to remember. When you're working with children, reinforcing in your discussions regularly. And this has to be consistent when you talk to them, when you ask them a question, then you can put your finger to your mouth that reminds them that they need to stop for a second and think. That's also an. Having some sort of cue, whether it's finger to the mouth or something else, is an important cue for when you're in public. When we used to go to the museums, my son loves zoos and museums. He loves science, enthralled with it. But he would, the people that would, the docents that would walk you around, he would be asking questions all the time. And you know, his mind was going so quickly and he would monopolize it. So we had to work with him and in order to help him allow other people to have a turn to ask questions and, and, and teach him. So when we would go to museums or places like that, obviously he was allowed to ask some questions. But we would put our hand on his shoulder and that would be his cue that he needed to hold his questions. And then if he still had them later, we could figure out how to get them answered. You can have people put a finger over their mouth for a few seconds as if they're considering what to say. Paraphrase what the person said to you. And this is something else that caregivers can prompt with older children. So have them repeat back to you, what is it that I just asked you to do? Or, you know, what is it that I. What is it that I just said? Encouraging them to paraphrase that and start using that as a mode of communication. And ultimately the final one, the person can imagine locking their mouth with a key to prevent themselves from speaking. And when you go to the movies with somebody with ADD adhd? Well, my son, you know, that's one of those things. He has to remember to keep his, his comments to himself when, throughout the movie or people would get very irritable. So we do have him, you know, now that he's older, we just tell him to remember to, you know, not blurred out during the movie, but when he was younger, we would use the. Imagine locking your. Locking your mouth with a key. The Job Accommodation Network. And we don't have time to go there right now, but if you go to the Job Accommodation Network or Jan, it has a lot of suggestions. And this link actually takes you directly to the page for adhd. It has a lot of reasonable accommodations that employers can be requested to make for employees with adhd. ADHD is a legit disability according to the Americans with Disabilities act, and as such, they are entitled to reasonable accommodations. This can help reduce that level of underemployment that we talked about on Tuesday. And if people are able to get into a work environment that. That is conducive and that is enhancing instead of not. ADD ADHD can negatively impact relationships, work and addiction recovery if not addressed. People with these issues and the people around them need to understand it's not a problem with willpower, but a condition caused by differences in the physical and chemical workings of their brain. As with any other disability, people with ADHD need to learn their abilities and be empowered to make necessary modifications to address their symptoms so they can live a life that is rich and meaningful. It's more important when working with people with ADD ADHD symptoms to identify and address the symptoms, then worry about whether they actually rise to the full level of the diagnosis. If you're working with an adult that has some residual symptoms, we still need to address those in order to prevent depression or anxiety. And Pat asked a question about dealing with COVID fatigue and these and people with ADD adhd. Can you tell me a little bit more what you're thinking about with COVID fatigue? A lot of people are experiencing high levels of anxiety right now because of a lot of different things. You know, politics, Covid, you name it, financial situations. So it is important, remember, to help them bring down that anxiety so they can bring down their. Or they can improve their ADHD symptoms. So that is one of those things that we really want to work with, helping them figure out how can they feel safe and how can they feel empowered, how can they, you know, addressing their cognitions that are contributing to their anxiety and evaluating and finding the facts for and against that belief and the and and identifying what parts of that situation they can control and what parts are outside of their control. Now that's a lot of stuff, especially for somebody with ADHD and high levels of anxiety. So the first thing is to really start helping them re regulate that HPA axis. Going back to one of the first slides, a lot of people with during COVID not with, not necessarily just with diagnoses, but a lot of people during COVID have gotten their circadian rhythms all out of whack. Their sleep's out of whack, and their alcohol consumption is way higher, up to 300% higher than it was before COVID All of those things will contribute to worsening ADHD symptoms. So looking, let's look at Maslow's hierarchy. Let's start at that bottom level. What can we do physiologically to help this person regulate their dopamine and norepinephrine symptoms? Then the next level, what can we help them do to feel safe and secure in this environment to reduce their anxiety? And then we can move on to starting to address some of the other ADHD specific symptoms. If this podcast helps you help your clients or yourself, please support us by purchasing your CEUs at Allce or getting your agency to sponsor an episode. 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