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.
Managing ADHD overload
1. CLEAR THE DECKS. When needed, hit the reset button. Forge a one-time amnesty, forgive the backlog, and begin from scratch. If someone is not yet able to do what is being asked every day, there is not much chance they are going to keep up plus catch up. If amnesty is not entirely possible, at minimum we distribute the backlog over time so that the total work required every day is sustainable. The goal is maintaining a reasonable amount of work each day, within what is possible for any individual.
Kids should not expect this type of amnesty to be constantly available. However, “responsibility” and “motivation” only follow from success, and success stems from asking kids to work within their actual ability level. Homework isn’t meant to bring to mind Sisyphus pushing his boulder up the hill, never to quite reach the top before it rolls down again. If they can get five things done each day and we keep asking six, eventually they’ll fall behind.
2. ESTABLISH A DAILY PLAN. Create a detailed and easy to follow daily checklist. Setting and sustaining a plan to manage homework is not intuitive to most children with ADHD. Knowing when to get started, predicting time, keeping track of books and assignments, and many related skills are all executive function related. So for starters, parents should set a homework time and create a distraction free place to get things done. If the after-school schedule varies, instead of a specific time the rule might be “work starts fifteen minutes after getting home.”
Most students benefit from a step-by-step, written checklist for how to complete work appropriately. For someone without ADHD, it may require breaking down the activity to what seems an inane level. To help make certain things get back to school, include a clear ending such as “put your homework away in your homework folder.” While working, children also often find it easier to focus with scheduled stretches on task interspersed with timed breaks (such as twenty minutes on, five minutes off). In-school supports involve breaking down assignments into daily parts, checking out with a teacher,end of the day, reminders to hand in work to the teacher, and countless other possibilities (the CHADD Educator Manual contains many more details).
We cannot use anyone’s actual age in judging what is possible, but instead monitor their development. A ten year old might have the skills of a six year old when it comes to organization. Unfortunately, there is no one perfect measure of executive function in real life, so instead we observe, make informed choices, and readjust based on how a child progresses.
Maybe they are not ready to manage their own to-do list at school. Maybe they cannot yet see how to break a longer project into its component parts. Maybe initiating their work after school is hard, or prioritizing time, or estimating how long various assignments will take each night. All of these difficulties and more occur with ADHD, and require direct support and instruction to cultivate independence. By sustaining this routine over months or even years of school, it becomes a habit that benefits all the way through adulthood.
3. EXTERNALIZE THE SYSTEM. Maintain adult support and involvement. Getting off task from a long-term plan is a routine part of ADHD, and does not typically stem from poor effort or laziness or whatever else seems apparent from the outside. Identify a parent, teacher, therapist, ADHD coach, or anyone else who can make sure the details are being followed. While written checklists and physical alarms also can act as external reminders, children need someone supervising with higher-level organizational skills.
A solid solution often involves parents and teachers almost taking over organization in the short run. Temporarily relief from responsibilities allows more energy for learning and keeping up with the more methodical plan you’ve created. A long-term plan hands back the responsibility only at whatever pace a student proves capable.
4. CONSIDER MODIFIED HOMEWORK. Avoid the counterproductive punishment of adding more and more to an already daunting load. In Understand Your Brain, Get More Done: The ADHD Executive Function Workbook (Specialty Press, 2012), psychologist Ari Tuckman writes, “It is vital to keep up with work as it comes— because it becomes impossible to do it all at the end. Homework can sometimes be (or feel like) a losing battle where it is impossible to keep up at all. At those times it may be helpful to speak about homework reductions, especially when a student is spending a lot of time but not getting enough done. If one knows ahead of time that homework will be an issue, you may be able to work with a guidance counselor to create a schedule for the coming year with teachers who tend to assign less.”
Children with ADHD should show good effort and do what is needed to learn; ADHD isn’t an excuse for slacking off. But they also should not spend their whole lives treading water, up to their necks in schoolwork. With ADHD, the goal is to find a groove where a child works hard but does not get consumed.
According to Dr. Tuckman, a strategic decision considers many factors, and demonstrates for a student with ADHD “a well thought-out process ... (instead of) simply running out of time and letting that decide what will not be completed or skipping tasks that they don’t like as much.” Prioritize more heavily weighted projects and classes with lower grades. Also, consider how much homework is required to actually support learning? How much will create a crisis? For any particular child, which projects and assignments have value? Which might be less useful right now?
Homework is meant to augment classroom academics. While the research is vague, the recommendation is around ten minutes per grade. Much more has the potential to undermine motivation and takes away from family time, down time, free play, and lots of other vital parts of healthy development. Someone with ADHD will be far more productive given at least some time to see family members, hang out with friends, play a sport, or maintain a hobby.
5. OFFER STRESS MANAGEMENT TOOLS. A first step to managing stress may simply be managing ADHD itself. ADHD compounds stress by making it hard to get anything done all day long. Even when life externally seems to be holding together, with ADHD every detail may be taking ten times the effort with five times the uncertainty. Assertive management supports long term success by balancing behavioral, educational, medical and even complementary options when appropriate.
Stress itself makes managing ADHD difficult. Under stress, most of us fall back on old habits, become more reactive, and lose our resilience. For an individual or family living with ADHD, these patterns make it harder to keep up with any plan. Working with a behavioral therapist or ADHD coach may both help in addressing executive function deficits and in developing stress management tools. The practice of mindfulness is also an evidence-backed, accessible way to manage stress.
6. CREATE AN EARLY WARNING SYSTEM. Schools should contact families as soon as assignments are missed. Fine-tuning the system requires almost immediate notification when it breaks down. Finding out about seven missed homework assignments over two months is hard to address, but finding out about two over a week is manageable. Don’t allow the back-up to happen in the first place.
If work starts accumulating, step back and look at the bigger picture: Can the child do the work asked of him, and has he had an appropriate educational evaluation? At least half of children with ADHD also have a learning disability and others have language delays. Others have fallen behind because of their ADHD. Assigned homework should consider present academic abilities and avoid material that is above a student’s ability level.
When assignments continue to be missed, consider if the student is able to handle the workload right now as it stands. Does he or she need more directed organizational supports? Modifications that cut back on the amount required each night? Does his or her medication need adjusting? Is homework even being done during the window of time medication covers?
In like a lion, out like a lamb Allowed to accumulate, the logistical details of life become overwhelming. But change is always possible. Through a combination of an external system, adult monitoring, and modification of work, homework should be manageable. As the system become more ingrained, efficiency rises and allows most students with ADHD to manage a workload similar to that of peers.
A slow drip of missed details can affect anything we must keep up with in life, but the same technique applies. Email piles up; the solution balances getting back to zero in-box and then creating a plan to keep up day to day. An astoundingly messy room (or house) maintains residence; start with a one-time effort to put everything in place while in tandem establishing a new system of some kind—maybe ten minutes of cleaning for everyone before bedtime. Balancing this short-term exertion with a realistic and empathetic long-term plan creates an entirely new way of living with ADHD.
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).