By: Kevin D. Arnold, PhD, ABPP
Sr. Executive Director, The Center for Cognitive and Behavioral Therapy

Board Certified in Behavioral and Cognitive Psychology

In a previous post, we reviewed the underlying problems in ADHD related to regulation of attention (both keeping it focused on less interesting tasks and shifting focus from more engaging tasks). The development of self-management skills relies on understanding this fundamental aspect of ADHD. Too, regulation of irritability in social conflicts exists as an equally unhealthy aspect of ADHD, and that too will be addressed below.

Regulating Attention and Impulsivity

For adults, as with children, most research indicates that ADHD benefits from the use of medications shown to be effective. The findings support that the neurologic mechanisms that have difficulty operating efficiently benefit from those medications. A first line for most individuals, either children or adults, includes the use of medication if it is tolerate and the negative side effects are manageable (e.g., loss of appetite).

However, for children with ADHD, other strategies also have effectiveness. For example, allow for shorter periods of work on less interesting tasks, with intermittent breaks, helps manage attention. Also, using positive attention as a reward, as well as other salient reinforcements, have shown to be helpful. The most effective approaches start of with frequent rewards, which are then thinned (spaced out) over time once attention control increases and impulsivity decreases. Programs like Parent Management Training or Barkley’s strategies are available with research supporting their effectiveness.

For adults, a program developed by Safren, Sprich, Perlman & Otto (2017) has shown good outcomes. The key strategies for adults focus on using information management and scheduling strategies. For example, using less structured notes each day that include key information (e.g., names, phone numbers, addresses) will help with forgetfulness later when the information is needed. Using general calendars and developing a habit of checking to-do lists on the calendar have also been shown to be effective.

Management of Interpersonal Conflicts

Folks with ADHD face increased impulsivity in response to interpersonal disagreement, and problems with suppressing that irritability in the service of longer-term goals. The emotional arousal can be very salient and attracts poorly regulated attention if medication has not assisted with activating the underlying neurologic mechanisms.

In children, the development of self-regulation of irritability benefits from both effective adult modeling as well as systematic rewards with positive attention/praise of non-hostile responses. A key issue for children with ADHD is the highly likely negative reaction of parents who become overwhelmed with repeatedly reminding their children to stop something, or start something. The irritability is

documented in research by psychologists such as Barkley. The unfortunate outcome of this pattern is that irritable reactions to children with ADHD model irritable reactions.

However, for children have been shown to benefit when parents receive treatment for positive parenting. There are several interventions for families, although one very straight-forward one is Kazdin’s Parent Management Training (Parent Management Training – Dr. Alan E. Kazdin (alankazdin.com)). In this method, parents are strategically taught how to recognize their children’s behaviors for improvement, deliver effective verbal instructions, and deliver praise when children do what they are asked. This method decreases impulsive reactions and increases compliance with parental demands for things like task completion….disrupting the cycle of parent-child irritability.

In adults, strategies for management of impulsive irritability not only include patients following any medication protocols (if in place), but also recognition of situational triggers and signs of arousal. For example, work situations that the individual with ADHD finds boring; however, that they must participate in, can be targeted for new ways of coping. Also, adults with ADHD can learn to self-monitor signs of irritability, such as increased heart rate or coldness in the hands and feet. Typically, setting up practice opportunities to mock irritability and learning to monitor physical arousal can assist in learning these signs and develop recognition of them through multiple practice sessions.

Once the skill of self-monitoring has been accomplished, adults with ADHD can create routines to use softer ways of expressing themselves or exiting the situation. The use of softer communication can be adapted from the Gottman method of “softened start-ups” and practiced during practice situations when irritability has been contrived. Also, making requests to excuse oneself (e.g., going to the rest room) and be coupled with relaxation or mindfulness strategies (staying present) in order to reduce physical arousal (i.e., reduce heartrates or slow breathing).

Summary

Whether with children or adults, people with ADHD can learn better functional skills for staying on task, maintaining attention, and managing irritability. If appropriate, they will likely do best if they adhere to a medication protocol, should one be in place. In addition, they can learn and use more effective skills to manage attention, information, tasks, and social situations. Often those skills require setting aside time to practice them in mock situations, and developing new routines and habits.

Resources Softened Start-ups: Extended ebook content for Ten Lessons to Transform Your Marriage: Exercise: Turning Harsh Start-up to Softened Start-up (randomhouse.com)

Barkley, R.A. (2020). Taking Charge of ADHD (4th ed.). New York: Guilford.

Kazdin, A.E. (2013). The Everyday Parenting Toolkit. New York: Houghton Mifflin.

Barkley, R.A. (2021). 12 Principles for Raising a Child with ADHD. New York: Guilford.

Safren, S.A., Sprich, S.E., Perlman, C. A. and Otto, M.W. (2017). Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program, Therapist Guide (Treatments That Work), (2nd ed.). Cary, NC: Oxford University Press.

Barkley, R.A. and Benton, C.M. (2021). Taking Charge of Adult ADHD: Proven Strategies to Succeed at Work, at Home, and in Relationships (2nd ed.). New York: Guilford.

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