Navigating Adult ADHD with Dr. Scott Shapiro

A lot of people go undiagnosed. Even though in the press there's been a lot of attention to the over diagnosis or misdiagnosis of adhd. With adults who have adhd, they do feel this inner tension and often leading to procrastination to avoid some of these feelings of anxiety or overwhelm.

Hello, I'm Dr. Farah White.

And I'm Dr. Grant Brenner.

We're psychiatrists and therapists in private practice in New York. We started this podcast in 2019 to draw attention to a phenomenon called the Doorknob Comment. Doorknob comments are important things we all say from time to time, just as we're leaving the office, sometimes literally hand on the doorknob.

Doorknob comments happen not only during therapy, but also in everyday life. The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking and experiencing. Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them. Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves. And sometimes we surprise ourselves by what comes out. Welcome to the Doorknob Comments podcast. Today we are here with Dr. Scott Shapiro, a leading expert on adult ADHD. Trained at Massachusetts General Hospital and Mount Auburn Hospital, both affiliated with Harvard Medical School, he served as director of psychiatry at St. Vincent's Catholic Medical Center's infectious disease unit in New York City and worked with the Hallowell Center, a renowned institute for ADHD treatment. In his private practice. Based in New York City, Dr. Shapiro specializes in adult ADHD, providing care to patients across New York and New Jersey. He blends psychopharmacology, medical psychiatry, and cognitive behavioral therapy to create individualized treatments for ADHD, depression and anxiety. Dr. Shapiro is also an executive coach and organizational psychiatrist, using his expertise to help executives, leaders, entrepreneurs, and other professionals enhance strengths and performance. He focuses on improving communication, leadership, productivity, performance, and emotional intelligence. He has written extensively about adult adhd, its treatment, and practical strategies to help individuals overcome their challenges. To access these articles, visit his website@www.scottshapiromd.com. Dr. Shapiro, it's been a pleasure getting to know you over these years and thank you so much for joining us today.

Well, thanks for inviting me on the show. I really appreciate it.

It's always fun to talk with folks we know. I always like to ask people how they got into this profession and kind of what it means, and I'd love to hear from you.

So the Way I got into the profession is a very interesting story. I knew that I was very interested in going into medicine and was planning on doing internal medicine. Where I'm from, which is the south, specifically North Carolina, people don't. During. When I was growing up, didn't really believe in therapy or seeing a psychiatrist, and there was a big stigma. However, when I moved to the Northeast, I decided that my true love and passion was psychiatry. And so I let go of some of those chains from. From growing up and decided to pursue my true passion and pursuing psychiatry.

It sounds like an important story, and I think a lot of people in our field, you know, have. Have come to it through their values, through courage, through heart. So I appreciate that. And I read in your bio, you. You had been the infectious disease. The head of the department at St. Vincent's that's right.

So during my training, I was very interested in the overlap between medical illness and psychiatry. And so I did a fellowship in an area called Consultation Liaison Psychiatry, where people with medical illnesses can have psychiatric issues that affect their medical illnesses and their psychiatric illnesses can affect their medical illnesses. And that intersection I found very, very interesting. So when I was looking to move to New York, I was looking for a position that I could continue my interest in the. This overlap between medicine and psychiatry and went to St. Vincent's Hospital, where there was a very large HIV and infectious disease clinic. And I ended up working there for 10 years. And it was fascinating because many people in that clinic, often their psychiatric illnesses, such as substance abuse or bipolar or schizophrenia, that often would lead to their risk factors for developing hiv.

Yeah, absolutely. It's an important field. And the role of, say, inflammation or the immune response in psychiatric illness is something that we've come to understand more deeply, but it's still very much important. I'll be curious later on how that may come up with executive function and attention problems as well. When I think of St. Vincent's you know, I used to supervise there. They had a great department of psychiatry and a lot of interest, as you said, in infectious disease and HIV being. Being at the. At the epicenter. In a lot of ways, St. Vincent's was down in the West Village. They, they. They closed. And a lot of people, you know, found it very meaningful working there.

I'll say St. Vincent's was a great community hospital. Some, some of the best, most committed doctors, nurses, staff. It really was, was a doctor's hospital and then the people's hospital.

A lot of history.

It was a great place to work.

I would love to Jump into adhd if that works for you.

Yeah, let's, let's talk adhd.

Okay, we're going to talk about adult adhd, which I think is certainly very common and can be very difficult for people. It's often goes unrecognized and un or undertreated. I know in my practice I will often identify people who have ADHD for a long time and it's often a heavy lift to get them into treatment. Once they're in treatment, it's often, it's often a game changer. So I would love to hear from you what, what is adult ADHD and how is it different from childhood adhd?

Well, that's a great question. And you know, one of the things that I love about working with people with adhd, especially adults, is that it's very common, it's often goes under undiagnosed, and that it's one of the psychiatric illnesses and diagnoses that is the most treatable and the most responsive to medication. In terms of how it's different from childhood adhd, children often will have outward signs of impulsivity and hyperactivity. So you may see them climbing all over, you know, at school or at home or on the subway. But when, as they get older, they've learned how to channel some of their energy. And so very often you will not see the hyperactivity and impulsivity as much. However, they often will have this restlessness, this sense of restlessness and internally. And so they may feel like internally they're not sure where to start, or they may feel overwhelmed by their emotions, or their mind is going to a thousand different ideas or a thousand different projects, but you won't see the hyperactivity and impulsivity as much. The other thing that's very interesting is that with adults, lives are a lot more complicated. They've got family, they've got lots of things going on with work, they've got their personal lives. And adults often require using an area of cognitive abilities called executive function and executive function, which is very interesting because it's not in the DSM 5 criteria. Executive function is a cluster of cognitive abilities that includes organization, prioritization, time management, sticking to a project over the long term, incoming going to completion, emotional regulation. And so often issues with executive function as well as emotional regulation end up being a much bigger impairment and challenge for adults than it is with children.

So sort of in a way, like if you had difficulty with the way you played sports, you had some trouble with coordination, it might be okay in grade school. But once you're in the major leagues, that underlying problem is harder to compensate for and really comes out.

That's right. And also the issues with executive function are really addressed very often in third grade, fifth grade, tenth grade by perhaps parents are more involved and kind of serve that executive function role. And also there's much more structure in school. You, you have classes that you have to attend, you've got work that you have to do. So with that added structure, there's less pressure on someone's ability to have strong executive function skills.

That makes a lot of sense. There's more support. And I hear that a lot when people enter adulthood, there's much less structure. And a lot of times undergraduate experience doesn't seem to prepare people for that structure comes up quite a bit in the workplace, especially with younger generations.

That's right. And often actually does start in college where for the very first time people are away from home, they may not have advisors or parents who are staying on top of them in their schedule. And, and there's a lot more autonomy, a lot more distractions. And you can start seeing people starting to struggle in college, but especially once they get out of college and they're in the workplace where expectations are a lot more ambiguous. Tasks are not necessarily so clear depending on what type of management you have. So the struggles can really start manifesting as a bigger challenge in college as well as, you know, as they start work as someone starts in the workplace. Yeah.

It can be a huge blow of course to self esteem and the world is less forgiving as we get older.

That's right.

You mentioned this kind of impulsivity and lots of different feelings of enter tension. Is there something people think that is before they realize it's adhd.

That's interesting. A lot of people go undiagnosed even though in the press there's been a lot of attention to the over diagnosis or misdiagnosis of adhd. With adults who have adhd they do feel this inner tension and often that can lead to problems with sticking to a task, to seeing a project through from the beginning to the end, and often leading to procrastination to avoid some of these feelings of anxiety or overwhelm. I would say procrastination is probably one of the top complaints that people have.

That see me and they can feel anxious as well. So you can go off treating anxiety, but you might be missing the mark.

Yeah. And going back to, you know, what, what do they sometimes think that they have? A lot of times they've seen psychiatrists before they see me or they've seen a therapist. And they often are misdiagnosed as having depression or as having generalized anxiety or really things such as personality disorders or ocd. For many of the people with adhd, they've developed coping strategies, especially the ones who weren't diagnosed and are thriving in the workplace. But some of the symptoms that, that they have that are helping them cope are often working two and three times harder than their colleagues and using strategies that from an outside perspective can even look like ocd. Obsessive Compulsive Disorder.

And is that because they are. They sort of know that they have a tendency or to, I guess, miss things or that they have trouble attending to certain details. And so they are just double and triple checking themselves in a way.

So people kind of have different paths that they've taken. For some people in terms of coping with the challenges they've had and it's gone undiagnosed. They can sometimes give up or procrastinate or avoid and just wanting to avoid that bad feeling of shame or defectiveness or failure. But for other people, and for many different reasons, temperament or how they were raised, they may be highly, highly motivated and realize that they're struggling and realize that they do need to check their emails three or four times or they do need to check if they have everything with them to go to work. And so they've developed coping strategies that for an apportion of the people can look like the obsessions and compulsions of someone with ocd.

Yeah, in my experience, there's often an inner sense of shame or embarrassment because there's a mismatch, right, between what the person knows they're capable of and then this fear of making a mistake. And a lot of times, right, they've had negative experiences growing up because people have just kind of come down hard on them rather than recognizing they have adhd. And of course that can lead to lots of what are sometimes called secondary problems with self esteem and so on. I think we can come back to that. I hear this question a lot. Does ADHD ever come on in adulthood or is it really always present from childhood? Because there's this thing on social media like adult onset adhd.

Yeah, that's a great question. That's a controversial area and there's a lot of research in that. In my opinion and in the research that I've read and in my experiences, I don't believe that ADHD comes on as an adult. The prevalence of ADHD in adults is between 4 and 5% out of those people, only 10% ever get an accurate diagnosis of ADHD or, or ever get treatment. So in my opinion, doesn't come on as an adult. If you really look back at their childhood or talk to parents or teachers or look at teachers comments, you can see that the symptoms existed quite early. Sometimes people aren't diagnosed at an early age for lots of different reasons, but one reason could be of high intelligence, that they may have very high intelligence, they're able to do well in school. However, when they enter a place like the workplace and other skills are required, such as organization, planning ahead, time management, politics, then their coping strategies no longer are helping them or effective enough for them to succeed. And so that's when they may seek out help and then get diagnosed. But again, when you carefully look back at their history and dig into some of the symptoms they had in their younger years or family history of other siblings who may have had adhd, you realize that it has been there and they were just using some coping strategies or, you know, have very high intelligence that they were able to compensate.

So it must be a relief to see people and be able to treat them for something that they've sort of been dealing with. I'm sure that it helps things tremendously, like in the workplace. But are there other benefits that you notice either in terms of people's relationships, you know, when they do get treated properly? Do you, do you see other things shift as you follow them over time?

Well, well, I do. I mean, it's very interesting. The people that often call me are not necessarily the individuals themselves. Often it's a spouse or a partner, so a boyfriend or a girlfriend or a husband or wife, or even if it's someone in their 20s, even, even.

Their mother, HR sometimes, right?

Or H. Absolutely HR that we've got a high potential here. But there's areas that they're struggling with. Once they do get treated, diagnosed and treated appropriately and also get the therapy to learn some of the strategies that they missed out on. So it's not just the medications, but it's also the, you know, effective therapy to help them. It also absolutely helps their home life relationships. If they're not in a relationship or they're not in a family, helps them to take care of things that they really struggled with, keeping their home clean, doing their laundry, paying their bills, showing up for their friends. So absolutely, a lot of other areas in their life do improve, such as relationships, taking care of themselves, feeling like they're competent adults in the world.

This sense of self efficacy there's a significant amount of research on how ADHD affects close relationships and you can imagine it's very easy to get into conflict. So if you forget someone's birthday and their attribution is you don't care about them, it's a very big reframe to say, oh my gosh, that's adhd. You made this point that it's more than just medication, you know, because people develop these coping strategies and if you only change the medication, then they don't, they don't do as well, you know. So we'll, we'll come to that. So what is the like the right way to evaluate and diagnose adhd given that there's often comorbidities, meaning other conditions at the same time.

So, so this is an interesting question. I know during my medical training and my psychiatry training we were not taught very much about either childhood or adult adhd. There may have been one or two lectures. And so many of my colleagues come to me and they ask me, how do you diagnose adhd? The way you diagnose ADHD is through the way you would diagnose bipolar or depression or anxiety is through a comprehensive clinical, clinical assessment. So I have all of the patients that I see where I'm evaluating them for ADHD fill out a comprehensive questionnaire about their symptoms, but not just in terms of adhd, but other potential medical disorders or co occurring, other psychiatric challenges that they've had, like anxiety or obsessions or insomnia or substance abuse. And then when I meet with them, I do a clinical assessment to see what challenges they're having, including not just the symptoms in the DSM 5, but also symptoms with executive function and emotional regulation. And what's really important is that people with ADHD are just known to be poor self reporters. So even if they minimize the symptoms that they have, I may speak to again, a partner, a spouse, a family member to get more information because very often an outside observer will notice the symptoms before the person themselves will notice the symptoms. The other thing that I use, which is not how you do the diagnosis but can help provide extra information, are different questionnaires or scales. So there's something called the Connor scale, which has a lot of research and validity to that, but and it's a self report. There's also something called the Weiss scale which shows how severe the challenges are occurring in the person's life. And I would say one of the most important things is to assess when the symptoms started and if there's some outside documentation. So I always request teachers comments and notes and grades from childhood. I'll ask for reports that the person may have from their managers, from work and if possible, speak to family members as well.

I find that's funny in psychiatry and I wonder if that has something to do with the stigma for mental health. Because if you go to another doctor and they send you for a workup, an echocardiogram, ultrasound, an MRI, etc. People will do those things. I know sometimes they can be quite delayed. But a lot of times in psychiatry I think there's a different desire or set of expectations that things not not be as careful or comprehensive. But I think that is the cornerstone is, as you said, a careful clinical eval. Wondering, you know, are there any ADHD lookalikes that aren't ADHD and when would psych testing come into play?

So, so both great questions. Let me answer the second question first. So a lot of people wonder, shouldn't we do neuropsych testing? Isn't that more quantitative? And actually I do not recommend in many specialists and researchers in adult ADHD also recommend that neuropsych testing is not indicated. It is a clinical diagnosis made by someone who has experience and knowledge and training in adult adhd. That someone, if you send someone for neuropsych testing to say this is going to automatically make the diagnosis. You can send someone who has ADHD where the neuropsych testing comes back and the person the testing showed that they, that they don't. And so you can, if you're just relying on the neuropsych testing, the diagnosis can be misdiagnosed. And then I've also sent people who absolutely don't have ADHD from the assessment and from knowing them for a period of time where I've sent them to a neuropsychologist and they've been diagnosed with adhd. And yet if you look at the clinical assessment, they don't have adhd. In terms of look alikes, they there are. That's quite extensive. So if we were to just break it down into medical and psychiatric. There's a lot of medical lookalikes, people with menopause can have symptoms of problems with attention, multitasking, organization, memory that can look like adhd. For example, I've had many people over all the years that I've been working who came to me and said, look, I know I have adhd, I just need you to talk to me, do the, do whatever assessment you need and give me the treatment. And their symptoms started right around when they became Perimenopausal and then went into menopause. Their symptoms do look alike. However, if in their childhood and teenage years that they did not have those symptoms, they then it's not adhd. And in terms of the diagnosis, that's not the, that it's not adhd. Other medical issues that can look alike can be things like people who go for treatment for chemotherapy. So I've had people come to me and they call it chemo fog or chemo brain that can, that can look exactly like adhd. Ovarian cancer especially, you know, that's something that's often diagnosed lately, later, often not caught until it's too late. Thyroid disorder, and I would say a big one. There's an overlap between, there's a high occurrence of sleep disorders in people with adhd, but someone could have a severe sleep disorder and not know it like sleep, like sleep apnea. And that can mimic the symptoms of ADHD as well as problems with executive function.

Yep. With certain cancers, there's something that, you know, as a CL psychiatrist are called paraneoplastic syndromes. That, that's why it's really important to have a careful clinical evaluation. As a side note, that's one of the reasons why kind of fly by night online diagnosis may not be best serving people.

Absolutely, absolutely. And a lot of that came out during the pandemic. But unfortunately where people were going online, you know, for five or 10 minutes, getting a diagnosis and getting a prescription.

Oh my God, you see this all the time. Fill in a form, talk to a professional, get a script. What about the brain fog that comes with depression and ptsd?

Yeah.

How do you think about that?

So going back to that, to that question, so the rule is really that with ADHD there's co occurring other psychiatric issues. So there's a much higher prevalence of depression, of anxiety, of ptsd, of bipolar disorder. And how do you kind of distinguish the two and pull them apart and then how do you treat them? One thing in terms of treatment, in my training I really learned treat the depression, treat the ocd, treat the insomnia. And they said, they said, well, if there's anything left over, you know, maybe get to the adhd. But very often they never would really focus on the adhd. In my opinion, very often the person's biggest challenge and source of suffering is really coming from the ADHD and not the depression, anxiety. And so in the majority of cases, my first target is really treating and diagnosing the adhd, except in certain circumstances where it'd be Contraindicated, such as especially bipolar disorder. You know, I would treat the bipolar disorder first and then treat the adhd. And what's interesting is when you treat the ADHD very often, even though it's a stimulant, and you may think that the anxiety may get worse. In my experience and with a lot of research, the anxiety can actually get better. People's depression can actually get better. Their relationships are improving and their work performance is improving. But in terms of distinguishing, do they have both or do they have one or the other? So if you were looking at ADHD and depression, you would really look at the timeframe. How long has the depression been present? How long has the ADHD been present? If it's symptoms, if the person has both ADHD and bipolar disorder. In adhd, you may have emotional dysregulation on a regular basis, but with bipolar, you have mood swings that go in episodes, like for three or four days with bipolar type 2 or weeks to months in bipolar type 1.

I think, you know, proper diagnosis and teasing things apart, you know, is probably the best thing that you can do for the patient to improve their life. But I'm wondering if we could talk a little bit about what it feels like, because I know that you have sort of some psychodynamic background. And what does it feel like for people to hear that a lot of the things that they assumed were laziness or, you know, apathy are really actually part of, you know, a psychiatric disorder.

Yeah. Or you even like a kind of a moral failing. Right.

Yeah.

Yeah. So I would say that the majority of people who were struggling, and not everyone with ADHD struggles in school or in college, but. But there they do struggle at some point, or else, you know, they wouldn't be coming through my door. But very often people that are. That are struggling with ADHD and weren't diagnosed, they may have had increased risk of bullying. They may have had a lot of negative feedback from teachers that they have higher potential than they're performing, and absolutely a lot of negative interactions with parents. And so when they get the diagnosis, I would say the majority of the people do have a sense of relief, of validation, because maybe even for a couple years, they've had a sense that maybe this is what was going on and a sense of hope that treatment, as well as therapy, could help them to feel better, to perform better, and for their personal lives to not have some of these challenges. There's also some other feelings, too, for some people, and again, it depends where on the life cycle they are but for some people, it can be a period of feeling a lot of anger that some of the. Many of the people that I've seen were actually a teacher may have said, you know, I think your child, you should go get your child evaluated for adhd, or they even were diagnosed, but treatment was never pursued because of maybe a bias with the parents. So there can be a lot of anger and regret when they find out the diagnosis. And then for many people, there can be some, I'm saying regret, but a lot of regrets of, wow, you know, people have been telling me something's going on or I suspected things, you know, now I'm in my 30s or 40s. Well, what would life have been like if this was diagnosed and treated sooner? So there can be some sadness and grieving and regrets.

Yeah, I see that. You know, myself and I do, you know, I used to try to tell people, well, we all sort of receive the treatment that we need when we need it. But you're right that sometimes, and especially with this idea of people being able to access information, which I think is overall a good thing, but because it's led to a lot of these pop up prescribing, I think that sometimes delays things and people aren't getting the right kind of care when they should be.

You know, and one thing that I think both of the all three of us are really talking about is really. And happens also in people that are diagnosed and treated as children, but especially those that go undiagnosed and untreated. What we're really talking about is what. And what's very prevalent is a sense of shame and failure and defectiveness. And I've written a few articles about this, that if you don't treat the shame and the defectiveness, then you're not really providing full treatment. That many people may get the treatment, and they may in terms of medications and therapy, but still in terms of how they feel like their core beliefs in cognitive therapy, you'd call this core beliefs. How they feel internally and what they feel their capabilities are, can. Can really hold them back in terms of pursuing goals professionally, hobbies, relationships. So I definitely think bringing up the idea and assessing for shame and defectiveness, as well as treating it and the ways that I treat it are using cognitive behavioral therapy in an outbreak of cognitive therapy called schema therapy, that looks at lifelong patterns and the schema that can often develop with someone who's undiagnosed with ADHD and untreated is the schema of defectiveness and shame and failure, like.

Their self Schema or sense of self, Right?

Absolutely.

Are there other forms of executive dysfunction? I mean, I think having an intense sense of shame about oneself causes executive dysfunction secondarily. But are there other, any, Are there any other formal diagnoses of executive dysfunction?

Absolutely. You know, it's very interesting recently there, well, not, I mean, for many years, but even more so there's been more interest recently that there. That people with other disorders can cause challenges with executive dysfunction. So some of them, which is very interesting is that you see it in bipolar disorder. And bipolar disorder is something where the more episodes you have before you get treatment, the more severe it can be. And they're starting to look at, you know, are there different subtypes where you. Where there's more executive dysfunction or other cognitive problems than in other disorders? Depression can cause trouble with executive function, severe sleep disorders. So many, many psychiatric problems and medical problems can absolutely cause problems with executive function.

Well, what would your thoughts be about things like difficulty with reading comprehension or dyslexia?

You mean in relationship to adhd?

Yeah.

So that's when I think that neuropsych testing can be helpful if someone, if there is a suspicion of dyslexia or a, or a learning disability. That's not something that would be assessed during a clinical assessment for ADHD, but could be discovered in an evaluation using neuropsych testing. But many people with ADHD do struggle with reading comprehension because of their working memory, which again is not a symptom of, in the DSM for adhd. But challenges with working memory are a classic symptom that go along with adhd. And working memory is being able to hold information for a short period so that you can do other cognitive processes. So for example, reading, kind of holding that information briefly in the previous part that you read so that you can comprehend as you continue to read, whether it's on an essay or an exam or, or, or fiction.

Yeah, that gets into making sense of things. It, it's a, maybe a different topic, but I'm quite interested in neuroscience and brain networks and I'm someone who treats patients with transcranial magnetic stimulation and treating folks with comorbid depression and adhd. And even after one day of intensive or accelerated TMS treatments, they, they report, even after less than one day, resolution of the brain fog and immediate improvement in attentional function. And it was curious. I was looking it up and I found a study and I'm interested to see what other research is coming out from 2020 where they treated patients with major depressive disorder. With TMS. And after two weeks, they found there were statistically significant improvements in what's called their central executive network. Which is. Is correct. Which is directly connected with what you're describing and it's the way like, you might manage those memory resources. It's just quite fascinating. But again, maybe a bit of a digression.

No, that, that's. That, that's very interesting. You know, I never thought of TMS as a potential treatment. There. There is a treatment that's actually FDA approved that's called trigeminal nerve stimulation, which has very few side effects and is effective. It's not something that I use to treat my patients, but it is one of the newer treatments. So it does make sense that TMS would also potentially be helpful. And I've even started seeing research to start exploring whether a new treatment that's very big in the news are psychedelics and whether psychedelics could potentially be a part of the treatment for adhd.

Yeah, the neuromodulation approaches are really interesting. We should definitely do an episode on those. Farah, do you want to move into talking about treatment a little more and more particularly coaching?

Well, I guess what I'm curious about is what does it look like when you start to see, when you start treating someone and you see some of their symptoms start to resolve, they're able to overcome some challenges. And one thing that I don't know if, if you guys have run into it, but I know there's a big stimulant shortage and I spend all my spare time calling pharmacies and I'm wondering actually if I could get a few tips for if patients are between their medicine or, you know, how do you support them all the way through? Because I know that you offer all these sort of wrapar treatments for it. So I'm curious about how they.

So it's a great question. The shortage has been absolutely challenging and people function before they were on the stimulants. And if there is a shortage, and thankfully for the most part, the majority of my patients have been able to find their medications and get treatment. But I do think that just using medications, you know, isn't enough to treat comprehensively the adhd. And so the type of strategies from cognitive therapy and schema therapy that I use is really to help them with whatever type of work. Well, one is in the workplace and one is in their personal life. And so in the workplace to really try to help them understand but also create strategies for overcoming procrastination. Working on projects such as a business plan or a developing a PowerPoint deck. So we work on very practical kind of nuts and bolts strategies of how to do their job. You know, for example, if you're a lawyer, you need to keep track of your hours. And that's something that many lawyers hate doing. But especially with adhd, it's much harder. So really developing some skills and strategies. And some of those strategies are things like, you know, there's a lot of neuroscience research that handwriting helps with memory, planning and focus. So very often people who have been for years struggling with keeping track of their schedule and trying to use a Google Calendar, I'll encourage them to use an analog old school week at a glance. And very often when they start doing that and seeing their schedule and handwriting their tasks that they need to do, that helps them. We also talk about very often they go into work and they're not sure, they've never kind of created a task list. So they go into work and for the first two or three hours are kind of, you know, maybe looking on Twitter or on Reddit. And then finally when they realize much of the day has gotten by, finally getting to some of their tasks. So we talk about starting to keep track of their projects, starting to keep track of their tasks, starting to break down things that may feel overwhelming, especially due to some of their schemas and core beliefs, into smaller tasks so that they're more manageable. And one thing that I would say is one of the most effective skills and kind of hacks to helping executive function and ADHD is finding an activity partner. So not delegating it, but having the person work with someone else in the room, talking it out, working together. This has tremendously helped a lot of my patients. So even the, you know, I would say that all the strategies I used are, are kind of are based within cognitive therapy. It definitely is much different. It looks much different helping someone with ADHD than doing kind of three column techniques and trying to track their adhd. You know, some of those types of exercises would be extremely challenging for someone with adhd.

Yeah, of course.

And just going back to the activity partner just for a second, you know, one time someone misunderstood it and thought that I meant to delegate. And he was really struggling in his small business because he wasn't getting to a lot of his work. And so for a month he was starting to delegate things with his administrative assistant. And he came back and I said, no, I would like you to spend the first two hours of every day working with your administrative assistant to work on your highest priority task and his sales just went way up and his productivity went way up and he just, he felt a lot better about what he was getting done.

That is a great. Do you have any. What are your top ways to help people? I know you've covered it implicitly, but specifically with procrastination.

So that can be a really hard one. You know, there's so many different causes for procrastination and often people don't realize. And here again, this is something that I've written a few articles on, on strategies to overcome procrastination. There can be lots of different reasons that make people with ADHD or any of us procrastinate. And the first thing is to realize is to understand what's causing the procrastination. Someone may again be working on easier task or not doing their work or doing other things. And so one cause can be maybe they don't have all the information and they're avoiding talking to their manager because they don't want to look stupid. Again, something that could activate or trigger the defectiveness. So they don't have the skills or the information. And that may cause procrastination. Another problem may be that the project or the task seems daunting or too overwhelming. So we'll talk about which parts of it seem daunting or overwhelming and some strategies to get around that. And one is breaking the task into smaller tasks. I think patients think this is a little bit funny, but I recommend that when they break down the task to start each task with a verb, so it doesn't just say article or email, but it actually says for 15 minutes, research and write out your first paragraph. And then step two might be read two more articles and write out your outline. And a small example might be, how does you know? A lot of people with ADHD avoid this, but how do you do your laundry? Well, if you write on your calendar laundry on Sunday, it's much more fun and much easier just to go outside and take a walk in the beautiful weather or hang out with friends. But if you break it down into tasks and it's really like five or six tests, go around your house and gather all the clothes, separate it in dark and lights, wash it, dry it, and then fold it. I mean, each one of those is really a micro test that you can put on your calendar and it's much less overwhelming to do. I mean, on a Friday night, in 10 minutes, someone could go collect all their clothes. And then in terms of folding and realizing you don't have to go from the beginning to the end that you could fold the clothes while you watch something on Netflix, you know, two days later helps a lot of the people overcome the procrastination. So when someone, and I would say this is the top issue that's getting in the way of people in the workplace really understanding what's causing the procrastination. Is it overwhelmed? Is it not having enough information? Is it that it's tedious? And then really collaboratively discussing strategies to overcome that.

Yeah. And what you're describing also makes it planning. Right. They're planning the steps implicitly, and they're avoiding this willpower trap. Like a lot of people say, I just need more willpower. And what you're also describing is like setting up the context so that it's likely to happen, rather than waiting and then getting into some kind of weird battle with oneself and.

Or attributing it, or beating, beating or beating your yourself up.

I mean, beating yourself up.

Absolutely.

Make. Making attributions like, oh, I avoid things because when I was a kid, like, I yada, yada, yada. Like, sometimes people attribute their procrastination to a psychological problem, but if it's really adhd, you have to approach it as adhd.

You covered a lot. I think you were so, so helpful and so generous with your expertise. And so I want to thank you not only as a fellow clinician, but also on behalf of our listeners. And I guess what I'm wondering is, practically speaking, how can people who might hear this take the first step, you know, where can they find you or someone like you to get started?

Yeah, so that's, you know, people are going to be listening to this podcast all over the country. And what I would recommend, especially maybe if someone's already seeing a therapist, is to first talk to your therapist, first talk to your psychiatrist. You know, one thing I didn't say, kind of as a little disclaimer, is that everything we've talked about is really educational and is not meant to be medical treatments. So please do not change your medications or change your treatment, you know, but really go back and talk to your doctor. And then where can people find treatment? Especially maybe in places that aren't large, large cities. I highly recommend people to go to academic centers, so places where. And it may be a little bit of a travel, but now with telehealth, that's more possible. And so really looking at medical schools, training programs, I think that you can really get access. And even if your preference is in person, the telehealth can actually help you get treatment from someone who specializes in adhd. And a big message I'd like to leave people who are taking their first step is that yes, there can be a lot of steps and it could be a little bit of a journey, as well as finding the doctor and therapist that you work best with, but to hang in there. And one of the strengths that people with ADHD have, yes, they procrastinate, but they can be very persistent. A little bit like a dog with a bone.

Tenacious.

So tenacious. And to really kind of use that strength. But when you, when you, when you reach out to a psychiatrist or psychologist or a therapist to ask them, how many do they specialize in adhd? How many people over the past year, how many of their patients, what percentage? And I would say to make sure that they say that they, out of the patients that they treat that at least 10 or 20% have ADHD. If they say, well, maybe one or two, that may not be the best person to see.

That's very good guidance. I'll say. It's also good to self educate. There's a lot of good online resources. We mentioned your website. And as part of my social media research, I do sometimes watch short videos online. I'm reminded of a recent study where they found that only 21% of videos on TikTok about ADHD had credible information. And as it happens, last night I saw the kind of shorts where they're saying, look at this picture. If you see this, you have adhd. If you don't, you don't have adhd. And so I think it's really important for consumers to properly vet the information that they're seeing and to go to credible resources like your website. Scott Shapiromd.com where else can people find you?

So, so I've got many articles on Psychology Today. I'm a contributor to Psychology Today. But I would say other websites that are credible would be places like the Cleveland Clinic, Harvard Medical School, apsart, which that's an acronym. APSARD is an association that specializes in ADHD and related disorders. And then there's another website that I came across that's specifically for adults with ADHD that's called adults with ADHD dot com. But I would go to these locations rather than TikTok because there's a lot of free information blogs as well as webinars that are available.

Yeah. And I certainly appreciate it when those credible sources put information out on TikTok. I recently became a member of. And this may be of interest to either of you. Fides F I D E S which is a a project of the World Health Organization to identify influencers who are credible and support them in sharing good health related information in mental health and in general health. So thanks very much. I think this has been really informative for me and I'm sure our listeners will appreciate it.

Well, thank you. Thanks for inviting me. I always enjoy teaching, sharing information and sharing my experience, so this has been so much fun.

Remember the Doorknob Comments Podcast is not medical advice. If you may be in need of professional assistance, please seek consultation without delay.