Tuesday, April 14, 2015

ADHD and Organizational Overload

by Mark Bertin, MD

Imagine that you are in ninth grade and you are given six assignments a day to complete. That’s a gross simplification over real life, which requires you to figure out when to do the work, how to do it, to coordinate various long-term projects, and to manage your busy life in general. But for now, imagine you need do nothing more than get those six things done... except you have ADHD and because of that you’re only capable of completing five.

Far from a disorder of only attention or hyperactivity, ADHD represents a neurologically programmed deficit in the exact managerial skills that allow you to handle everyday logistics effectively. So you continue to work diligently, even though people implore you to try even harder. By day two you have six more assignments plus one to make up from day one. By the end of the week, you’re potentially five assignments behind. By the end of the first month, you may be dozens of items behind—and now demands have risen to seven assignments a day. Whatever can you do?

An unexpected academic squall

There’s only so much any of us can accomplish in any one day. For someone with ADHD, that amount often shrinks compared to other people, since ADHD undermines cognitive abilities called “executive functions” that are required for planning, organizing, managing time, and prioritizing. So, where one person may be able to juggle a pressured high school academic schedule, two sports, and a social life, someone with ADHD may have used up their cognitive resources by noon.

Sometimes what had been a reasonable organizational plan no longer holds together as demands rise over time. Maybe before high school, not having a consistent to-do list or some type of logical plan to manage long-term projects was okay; not ideal, but manageable, and the procrastination did not impact life too much yet. By high school, there’s too much to mentally track and better time management becomes essential.

Each little bit not quite accomplished throughout the day rolls over to the grand life to-do list. It accumulates into an overwhelming and insurmountable pile, until eventually the whole system shuts down. A child with barely the bandwidth to keep up now is asked to make up an additional pile of missed assignments. Their cognitive gears lock when the combination of both doing their everyday work and their overdue list becomes literally too much to handle.

Stress is often defined as the perception that something in life is not manageable. The sense that the load has become impossible creates stress, which further undermines efficiency. Things fall apart—perhaps they stop working entirely. For some, it can even become “learned helplessness,” the assumption after repeated failure that there is no point to trying again. School anxiety grows and children may lie about their work, make excuses, or become oppositional in avoiding it. The solution lies in creating realistic daily demands that account for ADHD and implementing a structured organizational system that allows someone to maintain day-to-day control.

Take the rudder and hold on tight

Problem solving can be challenging even for a motivated child with ADHD. The executive function skills needed to identify the root of an issue, create a strategy, and stick to the organization system over time are all impaired. So instead of being able to pause, gather himself, and refocus as we might hope, the wheels come off entirely. He creates a plan that isn’t sustainable (I’ll stay up three hours later every night until I’m all caught up) or is inefficient to the point of increasing overall effort and stress.

To create a solution, we instead aim to “externalize the system”—when executive function is impaired, we build an external structure that supports it. Mental managerial skills are replicated through routines and reminders until they become more habitual. Thankfully, many tools support organization, ranging from day planners to sophisticated, smart-phone applications. This approach seems intuitive if you have strong executive function skills, but can be inherently difficult when you have ADHD.

Critical to implementing a new framework is recognizing the need for ongoing support from an adult. It does not quite make sense to expect someone to monitor a plan on their own if their core impairment is an inability to organize their life. Maintaining a compassionate perspective means recognizing that however it looks from the outside, the underlying issue is not effort or motivation but a developmental delay in executive function. In many ways, having ADHD undermines the exact skill set needed to start addressing ADHD in the first place.

Next week we'll look at strategies for managing ADHD overload.

A longer version of this post appeared in the June 2013 issue of
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Mark Bertin, MD, is a pioneering developmental pediatrician in private practice in Pleasantville, New York, and assistant professor of pediatrics at New York Medical College. He trains physicians, teachers, and psychologists in ADHD care and leads stress-reduction classes for parents. From 2003 to 2010, he was director of developmental pediatrics at the Westchester Institute for Human Development. He is the author of The Family ADHD Solution (Macmillan, 2011).

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