Intrinsic Motivation and Magical Unicorns

The art and science of time management.

Pills and Skills: What Can We Do While We Wait Out the Stimulant Medication Shortage?

With medications in short supply, what other supports can we offer?

I hear complaints about it all over the country - at ADHD-related conferences I attend and at the continuing ed workshops that I offer.  "My pharmarcy doesn't have enough supply of the ADHD meds to meet the demand."  

When I first heard rumblings of this in the Twittersphere, I thought it'd be a short-lived problem.  But as an article in Sunday's NY Times attests, the FDA continues to receive complaints about the shortage, and suggests that at least part of the blame is another government agency, the DEA.

Make no mistake, among evidence-based treatments for ADD/ADHD, stimulant medication is one of the best.   So a shortage of pharmacotherapy that helps students and adults function is a real crisis.  But could we use this crisis as an occasion to ask what else we can offer to individuals who struggle with time management, impulse control, and self-regulation?  

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There is substantial scientific literature - and a universe of clinical and personal experience - to warrant the following recommendations.  Not every one of these will be a good match for you or your family member, so pick one or two that you could easily begin to implement right away.  If it makes your life 10% easier, that will be a lot less stress, lost income, relationship challenges, and academic underperformance.

While my clients are waiting for the ADHD medication supply to catch up with need - or in addition to that medication - I like to recommend:

  • A really good calendar - paper or smartphone app - stuffed with commitments and activities and relationships that connect to what they know to be their personal core values.
  • A commitment to spend 10 minutes every morning reviewing their calendar, thinking about expectations ("What's expected of me today?  What do I need before I leave the house?") as well as variances ("What's different about today?  Where will I need the most focus and energy?  What routines are being upset today?") - and noticing what about my schedule today makes me feel energized, and what makes me feel numb and dead.  And committing to moving those things off my calendar - as soon as it's feasible and safe - to make room for more of what engages me and pulls the best from me.
  • The highest possible nutrition you can afford, given your current time and finances. Frequent small meals emphasizing protein.  Food which is less processed (fresh fruit is better than frozen fruit is better than canned fruit is better than fruit roll-ups is better than fudge).  Pay attention to how you respond to foods.  Your body is not lying when you feel really good (for me, it's rice and beans and cornbread - seriously) or really bad (for me, anything with maltodextrin, yikes!) after you eat.  What foods help you focus, and which make you feel wired and weird?  How much water is enough for you?
  • Regular (3-4 times a week) physical activity involving resistance training as well as cardio.  This could include weight training (like machines or free weights) and jogging or aerobics classes or treadmill.  Or one of the brisk yoga practices (like Ashtanga) includes bodyweight resistance as well as movement to get your heart pumping.  The research on the role of exercise in maintaining cognitive and emotional funcgtioning is compelling.  Adults feel better - and perform better on cognitive tasks - after a period of exericse, and the benefits last for hours.  Teachers rate students as less restless and more focused after an outdoor recess period.  
  • For parents of kids with attentional disorders, formal parent training will be a good investment.  Check out Collaborative Problem Solving and/or read Dr. Ross Greene's books for parents as a place to start.  Or google "contingency management."   When you're at your wits' end with an oppositional and distractible 8 year old, keep this in mind:  Your desired outcome is a healthy and well-adjusted 26 year old.  So what self-management skills are most important now as we consider the long road ahead?
  • For adults with ADHD:  Marry well and get a crackerjack assistant at work.  I've only halfway got my tongue in cheek here.  The point of this recommendation is twofold:  Surround yourself with positive social support (people who "get you" and love your unique characteristics and tolerate your challenged with attention and focus) and with family, friends, and coworkers who are good at the "executive" tasks (details, attention to time, paperwork) that may be harder for you.  
  • Get a coach.  Professional ADHD coaching requires time and financial commitment that may not be reasonable for everyone right now, but if I had a New Year's wish for everyone with ADD/ADHD it honestly would not be that their pharmacy had enough stimulant medication.  It'd be that everyone who struggles with focus and distractibility could have a supportive, trained, energetic coach.  Someone who knows who you are and what you really want at your deepest and "best," and helps you get out of your own way.  Someone who pops up (like the old Microsoft Word paperclip, but less obnoxious and more accurate) right when I'm about to veer off-course or waste precious time or fail to take the long view and say "Remember who you are, really, and what you want, really.  Remember exactly how good it's going to feed when you are that, when you do that."  This could be a professional ADHD coach, or it could be a friend or therapist or partner who really understands the strengths and challenges of life with ADHD.  For some, self-coaching is a way of reaping some of these benefits at work or school.
  • When they are absolutely required (and life does this) to do something hard or boring, I recommend my clients use a "chunking" technique.  For example, if you must do taxes or invoicing and you know you're like to get distracted, set a kitchen timer for 25 minutes and commit to working on that task until the buzzer sounds.  Then, take a break, respond to that text, or wind the clock up for another 25 minute "chunk."
  • Make use of a single in-box at the office.  One place to pile stuff that you haven't acted on immediately.  Then, weekly or so, go through the pile ruthlessly with trashcan at hand.  The single in-box principle applies to your calendar or planner as well.  Have one to-do list.   Google tasks is a great example, accessible by phone or 'puter.  My dad always has a tiny spiral-bound notebook in his shirt pocket - that works, too.  Those three or four things that are banging around your head right now - uncompleted tasks, emails, phone calls - put those on the list.  The great book you heard reviewed on a radio show during your morning commute?  Put it on the list.  All the things you'd like to do (be a better partner, increase your income, stop smoking) - put that on the single to-do list as well. Then, in your morning ten-minute calendar practice, review the to-do list and decide which of these a) you've got time for today, and b) connects closest to what you're really here to do and be and have.- what's most in keeping with your core values?
  • Finally, some practice which increases mindfulness.   You know that part of you that observes?  The part of you that, at the end of the day, notices whether you did or did not engage with the most important relationships and commitments?  That part of you that is essentially the same despite aging or health changes?  That is the essence of mindfulness, and although this is an important skill for all of us, becoming mindful may be crucial for young people and adults with attentional disorders.  If you've been accused of being mindless or careless, or you've looked back on choices and called them "impulsive," then for you this skill of mindfulness might be the place to start. 

Now, none of the above is easy.  Conducting research on these interventions has proven challenging, and expensive, for the same reasons that clinical ("real life") implementation is hard.  If you are a classoom teacher, 20% of your students will take up 80% of your time and energy.  If you're a parent of three children, one of whom has ADHD, he/she will require twice as much parenting as the other two combined.  And if you are an adult living with AD(H)D, you may have to work hard to do things that are really easy for someone else who's as bright and curious as you.  It's not fair, but it's probably true for you.

Pills don't teach skills (somebody had to say it).  They can give you a "foot in the door," and facilitate development and mastery of important self-management skills, but with or without medication, you or your loved one does need to learn skills.  So, while we wait out this stimulant medication shortage, which skills seem like the most important ones to tackle now?

 

 

 

 

 

photo:  stockxchng

David D. Nowell, Ph.D., is a neuropsychologist interested in motivation, focus, and fully-engaged living.

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