•  Your coach needs to help you continually return your focus to the work throughout a coaching session. Perhaps you will also need shorter sessions. If this feels  inconvenient  to a coach, they shouldn’t be working with clients with ADHD.

•  Chances are that you may fidget and squirm if you try to sit still for an hour. It’s not very helpful to fight it; save your mental energy for better things. Look for a coach  who isn’t distracted by it. Taking a walk during your session may help – are they ok with that?

• You will need and want to work towards getting to your appointments on time. If your coach feels upset by your lateness or takes it personally, understand that that’s their  issue.

• Trying to do tasks alone at home or work may not be a tactic that works well for you. Be sure your coach is flexible and will adjust their “normal” process to make things  work for you. If projects take longer than is usual with their other clients, that’s a fact of life that they must be comfortable with.

• I’d be surprised if you haven’t gotten into a life-long habit of “adjusting the truth” to sidestep criticism. This is very common for individuals with ADHD. A coach has to  understand this, help you take the time to give the most truthful answer and never take it personally.

• It is typical to forget, get distracted, go off on tangents, to get caught by an interesting idea or get bored. When your neurobiology is a certain way, you need to have  coaching that doesn’t ignore the facts.

It may not be obvious whether a coach has the experience and understanding you want until you’ve worked with them for a while. But these “issues” are an everyday part of life for many people with ADHD and your coach must not only accept these behaviors as a typical starting point, but must patiently address them as fundamental aspects of your work together.

Jay Livingston can be reached at LivingstonServices.com. Just use Jay@

You’re ready to head for bed, emotionally and physically wound down. Just a few simple routines to complete and you can drift into the mysterious state called sleep – check the doors, turn off the lights, brush, floss and settle into the embrace of your bed and sleep.

As you shuffle through the kitchen one last time, the image of a bowl of ice cream snaps into your mind. Wouldn’t the creamy, sweet, cold taste of a small bowl of chocolate be delightful? If
you slow your steps, you’ll likely open the drawer for the ice cream scoop.

It is possible to learn to resist at will. Try picturing something else. Focus on images of your bed or an experience you had of stepping on a scale that stopped short of where it previously was. Too hard? Picture a great play from the last game you watched or some other really good experience. Just know that if you stare at the freezer, you are more likely to indulge.

Have you had the experience of walking away from temptation and having the image weaken and lose its urgency? Try it as an experiment; walk away and see what happens over the next few minutes. Focus on paying attention to your reactions and the process of learning instead of the treat.

Controlling your impulses can be learned, whether it’s to stop putting junk food in your mouth or quieting your frustration with yourself, employees, colleagues or clients. Maybe you’ll never find it easy, always have to push to keep your focus, even fall off track sometimes when you’re
tired, but you can develop improved strength and technique with desire and practice.

Eight Quick Hints:

• Use distractions to pull your attention away from temptations
• Don’t re-evaluate previous decisions when you’re under the influence of temptations
• Develop an unbending pattern of behavior until you’re past thinking about a temptation
• Understand that developing will power (self-control) is a process of learning and practice
• Dump the old notion that your abilities or attitudes are set – they aren’t, you can learn new ways
• Notice, celebrate and savor small bits of progress
• Have a support person or group who you feel accountable to – who bolsters your self-control
• Live for the changes that you’re working on and practice them into being

Multiple past failures to grow your self-control simply mean you haven’t yet found the right approach. It’s discouraging, but learning is often a process of gaining knowledge from failures until you start getting a hint of which directions are successful. Try getting a new perspective (a coach’s
point of view) and more emotional support. Remind yourself, “With practice I can learn this.”

Want a more complete primer on how to improve self-control and self-discipline? I help people develop new habits and behaviors; it’s what I’ve been doing for over 30 years. Change takes practice and support, but the actual process is simple.

Jay Livingston

Jay@LivingstonServices.com

If your ADHD child does develop tics, don’t panic. Most of the time tics are benign and kids grow out of them even with no medical intervention. The peak age for symptoms of tics is approximately age 10 or 11 and then by adolescence usually the tics will begin to fade. Knowing that tics will generally improve on their own, how do you decide when to treat them? My simple answer – treat the tic if it’s bothersome to the individual and/or interfering with daily functioning. The decision should be a collaborative one among the patient, the patient’s family, and the treating physician.

Some of the medications we use to treat tics are actually blood pressure medications called clonidine and guanfacine. They work well to decrease the frequency and severity of tics. If you do decide to try these medicines, be patient. They take time to work and initially can cause some sedation, particularly in the first few weeks.

In children with combined ADHD and tics, prior studies have shown stimulant medications can exacerbate tics so the treatment may simply be to stop the stimulant. This is not to say that stimulant medications cause tics, in fact they don’t. Many patients with ADHD and co-existing tics are able to successfully take the stimulants. If however the stimulant medications do cause problematic side effects for your child, remember there are also non-stimluant medications for treating ADHD such as Strattera or Intuniv.

In summary, tics are fairly common with ADHD, are usually benign, and tend to improve by late adolescence even without treatment. Be able to recognize symptoms of motor and vocal tics in your ADHD child so you can talk to your doctor about treatment options.

Theresa Cerulli, M.D.

ADHD is known to be highly genetic. Approximately 77% of the time someone diagnosed with ADHD has the condition because of the genes they carry. However, genes are not the only factor. Researchers are finding other issues can “correlate” with ADHD. In this recent study published in January’s Journal of Pediatrics researchers show that neonatal health is an important risk factor for ADHD.

An astounding 980,902 children born in Denmark between 1988-2001 were monitored. The baby’s health immediately after birth was measured by commonly used Apgar scores. Then all children were followed from age 3 until a diagnosis of hyperkinetic disorder, a first medication for ADHD, migration, death, or the end of 2006, whichever came first.

The results – The lower the Apgar score the greater the risk for the child developing ADHD. Compared with children with Apgar scores of 9 or 10 at 5 minutes, the risk for ADHD was 75% higher in children than with Apgar scores of 1 to 4 and 63% higher for those with Apgar scores of 5 to 6.

Doctors concluded from this study that a low Apgar score is associated with risk of ADHD in childhood. Perhaps low Apgar scores and ADHD share common causes, or a low Apgar score reflects at least one possible pathway leading to ADHD.

Given the frequent use of CAM, I thought it would be helpful to review the common nonpharmacological treatment options for ADHD. Currently the most popular nonconventional ADHD therapies are as follows: dietary changes, herbal supplements, trace elements/vitamins, neurofeedback, essential fatty acids (EFA’s), and yoga/massage for ADHD.

In my experience complimentary and alternative treatments can be safely and effectively integrated with conventional approaches to treating ADHD. Despite the limited data, nonpharmacological treatments have indeed shown some benefits. For example in one research study using dietary changes to treat ADHD, 75% of children showed improvement in their symptoms when food colorings and additives were removed from their diet. Another study showed children and adolescents with low blood levels of ferritin (the storage form of iron in the body) experienced higher rates of ADHD-type symptoms, which improved with taking 80 mg per day of iron. More specifically the kids hyperactive and impulsive symptoms improved with the iron supplementation, but their inattentive symptoms did not.

In a separate small study, ADHD children practicing yoga demonstrated improvements in their symptoms over time compared to the group of ADHD children who did conventional exercise. In support of the argument for combined treatment, children who continued to take simulant medication simultaneously while practicing yoga showed the greatest benefit.

In summary, an integrative care approach - combining conventional with nonconventional therapies – may offer the best potential outcomes for those with ADHD. I encourage patients to talk with their doctors about all treatment options. It is important to inform your treatment providers of any and all interventions you are utilizing (or wish to utilize) so that safe and appropriate care can be implemented and the greatest benefit received.

I hear a lot of that kind of thing from parents of children I work with in my practice. They tell me they often feel stressed, overwhelmed and exhausted from their child’s frequent struggles and outbursts. Parents jump at the opportunity to learn some effective strategies for coping with this common challenge.

As children move through their day, they are bound to bump into situations that are potentially upsetting. Some children are born with calmer temperments and better self quieting skills, while others need to actively learn and be taught how to cope with everyday disappointments and frustrations in a positive way. This is one of the most important things a parent can help a child do. No child enjoys being out of control … it’s simply the only tactic he knows. The good news is you can help your child learn strategies to cope with his emotions constructively and have an easier time getting along in the family, with peers and in school. The bonus — you get to have stress relief, too!

Creating a “My Hard Times Board” (suggested by Peg Dawson EdD and Richard Guare PhD in their book “Smart but Scattered”) with your child utilizes an excellent tool for teaching him new calming and coping strategies. Remember these few tips before you begin:

• Child and parent collaborate throughout this entire process. 
• Choose a time to design this plan when your child is calm and receptive. Nothing constructive can be developed during an outburst!
• Make sure there’s plenty of opportunity for practice each day. After all, Tiger Woods could never make those spectacular putts without lots of it. Even he misses on occasion and so will your child. Mistakes will happen – you can bank on that. But, your child will be reassured when you let him know that there’s always another chance to try again later.   

STEP I: Together with your child, identify and record a couple of the most common triggers to your child’s outbursts (i.e. parents say “no,” plans don’t work out as anticipated, your child is told to stop doing something fun to do something less enjoyable, your child thinks things aren’t fair).

STEP II: Together, list and record your child’s “can’t do” behaviors that he often uses when he is frustrated (i.e. yell, hit, throw things).

STEP III: Together make a list of your child’s “can do” behaviors to replace the undesirable ones that occur when he is beginning to feel upset. This list is most effective when your child’s personal interests are represented so that his choices are engaging and interesting to him. (Examples of “can do” strategies follow after Step IV).

STEP IV: Now that the board or chart has been designed and your child is invested in the process, it’s important to keep it going by implementing the following concepts.

• A good way to get started is to have your child choose one of these strategies (that follow) and practice the technique with your child for a few minutes each morning and after school. During each practice have your child pretend he is getting upset, describe the body sensations he feels when he is angry and rehearse his calming strategy. Expect to practice these strategies many times before seeing your child using them successfully. Research tells us that it takes 21 days to make a new habit.
• You and your child might want to develop a special signal, a visual or verbal cue, that is a reminder to use one of his calming strategies. Remember, when your child chooses one of the positive behaviors on his “can do” list, it’s time to offer up enthusiastic praise and even tangible incentives such as stickers, rewards or special activities. Everyone loves a prize for a job well-done! 

Here’s a sampling of “can do” strategies for calming and redirecting behavior. Personalize this list by creating names that resonate with your child.  

• Happy Birthday:  Teaching children to take deep breaths when they begin to get upset may seem simplistic, but it’s a lifelong skill for managing stress that has emotional, behavioral and physical benefits. Explain to your child that we all have warning signs that tell us we are getting angry. Help your child recognize the signs his body is sending out that lets him know that he’s getting angry (i.e. face gets red; fists clench; heart pounds; breathe faster). When he feels the warning signs, have him take three deep breaths. Next have your child hold up his hand, palm toward his face with fingers spread. Coach your child to blow on each finger as if he is blowing out five birthday candles, one at a time and very slowly. When you see your child getting frustrated, you might say, “Now might be a great time to blow out the candles.” In the beginning you might want to do the breathing along with your child. Set the pace, modeling for your child and letting your calm presence soothe him. 
• Cozy & Cool:  With your child’s help, create a “safe spot” where he can go to regroup. This special, positive place in the house is where he can go to calm down, sort things out or just chill out when he needs to be alone. It could be a teepee, a beanbag chair, a hammock, or any space your child sees as comfortable and inviting. In the “safe spot” include soft items like blankets, stuffed animals and a basket of quiet time activities that he can play with while relaxing (books, puzzles). Encourage your child to go to his “safe spot” when he feels himself becoming upset. Teach him that sometimes in an angry situation it is best to walk away, go to his “safe spot” and cool down.
• My Never Never Land:  Use relaxation visualization to design an imaginary place that makes your child feel calm. Help your child create a mind picture of a special place that makes him feel peaceful with all of the colors, sounds, textures, and smells that go with the memory. For example, a child may have a happy memory of a time at the beach. When he feels upset, he can take a “trip to the beach.” He can close his eyes, smell the ocean air, feel the sand between his toes, and feel the sun shining on him. Given the opportunity to run with this, your child may add props to further enhance the experience. One child I know took his towel and sunglasses to his “beach retreat” whenever he needed a “beach break.”  How clever is that!
• Picasso’s Playground.  Build a spot that includes an array of art materials that can be used independently as a calming and quieting activity. For some children, working with clay, drawing, or doing crafts is soothing and distracts them from the dilemma at hand. As time goes on, try adding new items to keep up the novelty and high interest of the center. Parents, keep a ready supply of items to have on hand so that you can change and rotate art supplies as needed. Keep your eye out for those treasures that might hold your child’s interest.
• Shake, Rattle & Roll:  Your child can take a walk, shoot baskets, jump rope, swing on a swing, kick a soccer ball, bounce a ball, or dance to his favorite music. Some children get calming benefits from physical release. 
• Beatles & Beethoven:  Create a listening center with a CD player and earphones where your child can go to listen to music, books on tape or sing a song into a microphone. Dust off that old karaoke machine!
• Splish Splash … Takin’ a Bath?  For some children, water is soothing and comforting and gives distance from the problem at hand. Try bubbles in the sink, sprinklers in the yard or an old fashioned bubble bath.

There is no single strategy that is good for every child and every family but with lots of practice, role playing, and simulations, children learn new calming techniques that can help them think before they act. Over time, the goal is for your child to develop both the skill and confidence to handle difficult situations on his own without getting upset and losing control. Remember the best way to teach kids how to manage upsetting feelings constructively is to model calmness through your example. Together, and with a lot of patience, much love and lightheartedness, you and your child will find a calmer and more joyful path.

  Doreen Fay EdD

What do we mean by emotional impulsivity? Why does this matter? Examples of emotional impulsivity include impatience, quickness to anger, easily frustrated, over-reactive, and easily excited. These characteristics are frequently seen with ADHD, yet often unrecognized as a core part of the condition. Frighteningly, these folks may be misdiagnosed as having a mood problem such as depression or bipolar disorder instead of what is really going on – their ADHD!

Over the years in practice I have seen many ADHD kids mistakenly labeled as bipolar. Their over-reactive nature gives an impression of a mood problem when the child is instead struggling with self regulation of attention and behavior. They have difficulty putting on the brakes in their brain. Similarly adults with ADHD can be impatient or emotionally over-reactive, which could lead to misdiagnosis. Unrecognized and untreated these features of ADHD can lead to problems at work and home.

I should also mention ADHD frequently does co-exist with Depression, Anxiety, Sleep Disorders, Bipolar disorder,etc so it is indeed possible to have more than one condition. Making an accurate diagnosis can be tricky. If you are seeking an evaluation for ADHD, I encourage you to work with professionals who are specialized in this area. Getting an accurate diagnosis is essential to getting the right treatment.

Theresa Cerulli, M.D.

“I always say I will get a project done early, but I never have. I always just end up feeling like such a loser and then I do it again the same way next time. I can’t change.”

Ron came into our first meeting and said his wife was about to leave him because he was never on time.

“I promise to be home before the kids are in bed, but then I just get caught in a project at work and it’s 9:00 PM before I get home. I’ve tried everything, but I’m just not going to change.”

Sheila and Ted were referred by Ted’s doctor for couple’s coaching. When I asked, “What would your life look like if it suddenly improved?” Sheila’s frustration just burst forth.

“He keeps telling me that he’ll do better, but it’s been fifteen years and he still never gets anywhere on time. Am I supposed to act like that’s normal?”

Ted looked up sheepishly and reported, “I feel terrible and I know I’m impossible to live with, but no matter what I try it doesn’t work. I’m just a mess; what can I do?”

Each of these clients ended up making changes that made life easier for them and for their spouses and work colleagues. And where did I suggest they start? By forgiving themselves.

A study by M. Wohl et al, detailed in a paper entitled, “I Forgive Myself, Now I Can Study: How Forgiveness for Procrastinating Can Reduce Future Procrastinating,” gives some interesting evidence that forgiving yourself for messing up can help free you to give a better effort at trying again.

In my practice I’ve seen that an increased ability to implement a new approach, along with an effective technique and the support of an understanding ally can make a huge difference. I encourage my clients to pay close attention to the fact we’re talking about forgiving themselves. And while it may be helpful for their spouse to forgive them, it’s the self-forgiveness and then a sincere new effort that is key.

Did you know that old dogs can learn new tricks? And people of all ages can and do learn new ways to act in their lives, especially if they can forgive themselves for past mistakes.

Give a call if I can help, 978-446-9600.

Jay Livingston

Phase delayed sleep is the most common sleep disorder that accompanies AD/HD. Phase delayed sleep disorder is a fancy way to say the person goes to bed too late and then has trouble getting up in the morning. The hypothalamus in our brains helps to regulate sleep/wake cycles and is basically malfunctioning in an individual with phase delayed sleep.

Is your family short on rest? Try good sleep hygiene including consistent sleep/wake times and creating comfort around your bedtime routine. Reduce energizing activities a few hours before going to bed. Leave the shades open so sunlight shines through early in the morning; light tells the brain it is time to get up!

When behavioral strategies fail, consider over the counter remedies such as melatonin or valerian root. These are natural supplements that help induce sleep and have some clinical research studies to support their benefits and safe use.

You may also want to talk to your doctor about medication. There are newer non-addicting sleep medications such as lunesta and rozerem that have been FDA approved for chronic use in adults and other medication options for children with sleep issues. In our practice I do prescribe sleep medications temporarily to assist patients in getting on a good sleep schedule. Once sleep is well regulated, we recommend weaning off the medication and using behavioral strategies to continue getting your zzzz’s.

Have a restful night!

Theresa Cerulli, M.D.

This might be a fun puzzle if it weren’t so crucial that you find a way to get started changing your approach. One of the common side effects of procrastination is that people in your life lose trust in you and get angry. As you well know, this is usually matched by your own anger at yourself. But this pressure usually doesn’t translate into motivation to get started.

If life were a sport and you were critiquing yourself for missing critical shots because you didn’t keep your eye on the ball, I’d be pointing out that your focus on past mistakes is taking your attention away from the current situation, taking your “eye” off the ball again. Drop the self-critique, get a bit of help with your technique and try again.

The best hitters in baseball look for, and can see, the stitching on the ball as it comes at them at up to a hundred miles an hour. They know that they need to look for this detail to pull their attention to the ball; just looking in the direction of the ball doesn’t allow them to see the tiny changes in directions that they need to see in order to connect with the pitch. Golfers watch the dimples on the ball as it sits on the tee.

To get started on a project, focus on the details of getting started. What project will you start? Schedule it in your calendar. What small, discreet aspect of the project will you do? Define it and plan on doing just that much. What exactly will your next action on the project be? Write it out very simply as a task.

Think about teeing up the project – choose which one you’re going to work on.  Keep your head down, your eye on the ball and hit it just well enough to move it down the course and keep it in the fairway – do a small piece of it.  Now you’re ready for the next shot – concentrate on the new swing no matter whether you’re in the rough or on the course.

For you baseball fans, what you’re looking for is a single, not a home run; don’t over reach. Just connect with the pitch. Basketball aficionados, take one step and move the ball down the court. Every foot closer to the basket increases the odds of a score. Tennis players, make a solid smooth hit and get the ball across the net and into the court. Now set up for the next shot.

What do you need to get done? Right now schedule a time to work on it, and resolve to treat it like an important meeting. What is the first little step to getting the project started or moving it ahead? Write it down on your task list.

Procrastination can be head faked that easily.

Contact Jay Livingston