spect thinks the task is important to tackle and to complete.
3. the concept of rewards for doing a task and conse-quences/punishments for not doing it.
A person with an ADHD nervous system has never been
able to use the idea of importance or rewards to start and do
a task. They know what’s important, they like rewards, and
they don’t like punishment. But for them, the things that motivate the rest of the world are merely nags.
The inability to use importance and rewards as motivators
has a lifelong impact on ADHDers’ lives:
How can those diagnosed with the condition choose
between multiple options if they can’t use the concepts
of importance and financial rewards to motivate them?
How can they make major decisions if the concepts of
importance and rewards are neither helpful in making a
decision nor a motivation to do what they choose?
This understanding explains why none of the cognitive
and behavioral therapies used to manage ADHD symptoms
have a lasting benefit. Researchers view ADHD as stemming
from a defective or deficit-based nervous system. I see ADHD
stemming from a nervous system that works perfectly well
by its own set of rules. Unfortunately, it does not work by any
of the rules or techniques taught and encouraged in a neurotypical world. That’s why:
ADDers do not fit in the standard school system, which is
built on repeating what someone else thinks is important
ADDers do not flourish in the standard job that pays
people to work on what someone else (namely, the boss)
thinks is important.
ADDers are disorganized, because just about every
organizational system out there is built on two things—
prioritization and time management—that ADDers do
not do well.
ADDers have a hard time choosing between alternatives,
because everything has the same lack of importance. To
them, all of the alternatives look the same.
People with an ADHD nervous system know that, if they
get engaged with a task, they can do it. Far from being damaged goods, people with an ADHD nervous system are bright
and clever. The main problem is that they were given a neurotypical owner’s manual at birth. It works for everyone else,
not for them.
Don’t Turn ADHDers
The implications of this new understanding are vast. The first
thing to do is for coaches, doctors, and professionals to stop
trying to turn ADHD people into neurotypical people. The
goal should be to intervene as early as possible, before the
ADHD individual has been frustrated and demoralized by strug-
gling in a neurotypical world, where the deck is stacked against
him. A therapeutic approach that has a chance of working, when
nothing else has, should have two pieces:
Level the neurologic playing field with medication, so
that the ADHD individual has the attention span, impulse
control, and ability to be calm on the inside. For most
people, this requires two different medications. Stimulants
improve an ADHDer’s day-to-day performance, helping
him get things done. They are not effective at calming the
internal hyperarousal that many with ADHD have. For those
symptoms, the majority of people will benefit by adding
one of the alpha agonist medications (clonidine/Kapvay or
guanfacine/Intuniv) to the stimulant.
Medication, though, is not enough. A person can take the
right medication at the right dose, but nothing will change if he
still approaches tasks with neurotypical strategies.
The second piece of ADHD symptom management is to
have an individual create his own ADHD owner’s manual.
The generic owner’s manuals that have been written have
been disappointing for people with the condition. Like everyone else, those with ADHD grow and mature over time.
What interests and challenges someone at seven years old
will not interest and challenge him at 27.
Write Your Own Rules
The ADHD owner’s manual has to be based on current successes. How do you get in the zone now? Under what circumstances do you succeed and thrive in your current life? Rather
than focus on where you fall short, you need to identify how you
get into the zone and function at remarkable levels.
I usually suggest that my patients carry around a notepad or
a tape recorder for a month to write down or explain how they
get in the zone.
Is it because they are intrigued? If so, what, specifically, in
the task or situation intrigues them?
Is it because they feel competitive? If so, what in the “
opponent” or situation brings up the competitive juices?
At the end of the month, most people have compiled 50 or 60
different techniques that they know work for them. When called
on to perform and become engaged, they now understand how
their nervous system works and which techniques are helpful.
I have seen these strategies work for many ADDers, because
they stepped back and figured out the triggers they need to pull.
This approach does not try to change people with an ADHD nervous system into neurotypical people (as if that were possible),
but gives lifelong help because it builds on their strengths. A
WILLIAM B. DODSON, M.D., board certified in psychiatry, specializes
in treating adult ADHD in Green wood Village, Colorado. This article
is adapted from his forthcoming book, What You Wish Your Doctor
Knew About ADHD.