194. Treating ADHD Without Medication: Tips to Improve Focus & Productivity feat. Dr. Nick Nissen

Jun 29

listen to this episode:

Today's guest is Dr. Nick Nissen— a Harvard-trained psychiatrist, researcher, journalist, and expert in ADHD. In his concierge psychiatry practice, Nissen Clinic, he uses a suite of evidence-based treatments to get to the root of ADHD without using stimulant medications.

In this episode, we discuss:

+ Genetic and environmental components of ADHD

+ Self-diagnosing and misdiagnosing ADHD

+ The pros & cons of using stimulants to treat ADHD

+ Ways to improve executive functioning without using stimulant medications

+ Strategies for staying organized & improving motivation for people with ADHD

+ How people with ADHD can improve their focus

+ Recommended resources for people with ADHD

+ Daily habits people with ADHD should try to implement

+ so much more!

Dr. Nissen's Instagram: https://www.instagram.com/dr.nissen/

Mentioned In The Episode…

+ Nissen Clinic

+ Getting Things Done

+ Atomic Habits

+ Bullet journal

+ Shimmer

SHOP GUEST RECOMMENDATIONS: https://amzn.to/3A69GOC

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About She Persisted (formerly Nevertheless, She Persisted)

After a year and a half of intensive treatment for severe depression and anxiety, 18-year-old Sadie recounts her journey by interviewing family members, professionals, and fellow teens to offer self-improvement tips, DBT education, and personal experiences. She Persisted is the reminder that someone else has been there too and your inspiration to live your life worth living.

a note: this is an automated transcription so please ignore any accidental misspellings!

Sadie: Welcome to She Persisted. I'm your host, Sadie Sutton, a 19 year old from the Bay Area studying psychology at the University of Penn. She Persisted is the Teen Mental Health Podcast made for teenagers by a teen. In each episode, I'll bring you authentic, accessible, and relatable conversations about every aspect of mental wellness.

You can expect evidence-based, teen approved resources, coping skills, including lots of D B T insights and education in. Each piece of content you consume, she persisted, Offers you a safe space to feel validated and understood in your struggle, while encouraging you to take ownership of your journey and build your life worth living.

So let's dive in this week on She persisted.

Dr. Nissen: You know, Sometimes, people find it very helpful to have a clear diagnosis. And sometimes people, are able to say, Well, who cares whether or not I have it or whether or not I have a diagnosis? Like, let's just figure out how to make me better at focusing, , and more effective.

, and I would say certainly for anyone out there, That, , whether or not you have ADHD, if you are having problems with your performance in school or, professionally, then the things that we're going to talk about today will be helpful for you.

Hello, hello, and welcome back to another episode. I don't have my normal microphone today, so sorry if it doesn't sound as crisp and clear. But we have a great episode that was recorded with the correct microphone. We have Dr. Nick Nissen on the podcast today. He is a Harvard trained psychiatrist, researcher, and expert in ADHD. And we talk about all the skills that you can use to navigate ADHD like lifestyle changes, supplements, medication, executive functioning skills, therapy, and different technological shifts you can make to really get to the root cause. And a lot of what we talk about in this episode is treating and coping with ADHD without stimulants. I know you guys always love the ADHD episodes, and this one does not disappoint. So, without further ado, let's dive into this episode.

Sadie: Thank you so much for joining me on She Persisted. I'm so excited to have you here. Episodes about ADHD people always love and have so many questions about, and it's definitely a topic that people are becoming more and more aware and curious about, and so I'm really excited to get your thoughts on all things.

not taking a medication approach, what changes people can make in their lifestyle, , and then also your background and career. So thank you for coming on Cheap Assistant.

Dr. Nissen: Absolutely. Thank you for having me.

Sadie: Of course. Okay. So for people that are not familiar with your background or your career, can you explain how you got into specializing in this specific area and becoming an expert in ADHD?

Dr. Nissen: Absolutely. So I'm Dr. Nissen. I'm a psychiatrist and my, , my, my training, , I guess I, I went through formal medical training and sort of the first part of becoming a psychiatrist. So, , I did undergraduate at the University of Notre Dame, medical school at Brown University. University and then, , psychiatry training at Harvard Medical School.

And it was really at Brown that I started to really fall in love with psychiatry. , I was seeing, I'd always thought that I wanted to be a surgeon and do cleft lip and cleft palate repairs because I felt like it was, you So terrible, to be in a situation where you'd be born, , you know, with a condition , were in many parts of the world where you would be, you know, bullied or rejected because of it and, , and really wanted to help with , that stigma.

And then I did my required psychiatry rotation and I realized that there's so much stigma and mental illness. And it was something that I had experienced, you know, with, with friends and loved ones growing up, but I think it really, , yeah, it really impacted me during my training. So, , then as, you know, going through my psychiatry training, I was realizing that ADHD was an issue that was on people's minds, , you know, as you know, in the last few years during COVID.

A lot of people were converted to fully virtual workspaces, fully virtual, , educational spaces, and they were all feeling scatterbrained. And actually during the pandemic, , the, the rates of ADHD diagnosis surge and the rates of prescribing of ADHD medications surged. , and I think a lot of people were sort of confused by that and also, , scared by that.

, a lot of the, the medications, , that are used for ADHD have side effects and they have concerns associated with them. So, , you know, I really felt a need to think of well, How can I sort of make this clear for patients what ADHD is and then also what their options are that are available to them so they don't feel like they are, you know, only given one possible solution being Adderall.

So I wanted to look beyond that.

Sadie: Can you give us that explanation that you give patients? I think it's very helpful, especially for people that are listening with a sibling or a friend that has ADHD and they're not super familiar with the diagnosis or the implications in school and work and just day to day life.

So how do you explain that to patients?

Dr. Nissen: Absolutely. So ADHD is a neuropsychiatric Disorder, which means that it's a disorder that has a strong footing in both, , the hardware and the software of the brain. , you could have, and I have had one patient who had a stroke in, in one specific area in the front of the brain, and he, He had, you know, wildly severe ADHD as a result of that.

So there's definitely, , a physical, possible physical source to it. But then there's also a behavioral source to it. there's a problem with software or there's a problem with, , nature nurture. there's a problem with, , nurture. There's ways that you can make it worse. And certainly, , being in situations that, that don't train you to hold your attention for a long time, like a lot of social media is nowadays.

, that's a way that's gonna train it to be, , to be poorer. , and so, a way that I like to talk about it for people is that it is, It's a problem of both, , nature and nurture for people. There's a strong genetic backing to people that have ADHD. , so there's a genetic risk profile that needs to be considered.

If you have parents that have ADHD, if you have siblings that have ADHD, it makes it more likely that you have ADHD. , and then there's also varying severities of ADHD. So some people have. very mild symptoms and they're able to just kind of figure it out on their own and, and, you know, still do well. And then there's very severe ADHD where you can imagine, you know, where somebody can't even, , put together a short list of to do's or they don't even have a calendar or haven't been able to set up a calendar and remember to check it.

, those sorts of people never hold jobs or, , or aren't able to, to get a career or graduate any classes. So there's a whole range of severity. , and then the other thing that I would say is that there's a lot of, , diagnostic uncertainty out there. , many people think that they have ADHD, , but probably, you know, a fraction of those people do actually have ADHD, meaning that it's significant enough to cause impairment in their functioning.

, and it's something that develops typically in childhood, , and that has notable impacts across multiple environments, , as they're growing up. , , and, you know, people can have lapses in their ability to concentrate and focus in depression, for example. So sometimes people have undiagnosed depression, they have difficulty focusing, but they're also, you know, relatively sad or, you know, depressed.

Low energy and it's it turns out it's actually depression and not ADHD or maybe they have low thyroid and they feel very You know very fatigued or they have anemia and they feel, low energy and difficulty with concentration. So , that's why it can be important to have an evaluation by a medical doctor or psychiatrist To really make sure that this is what you have So that you can go about trying to treat it

Sadie: You mentioned that a lot of people think they have ADHD but they don't actually have ADHD.

And this is a really big thing on TikTok. There is like a whole adult ADHD movement and you see so many people being like, I just found out I have ADHD or like my ADHD brain. And when you look at the data, like the percentage of the population that has ADHD, it doesn't really match up with what we feel like we're kind of seeing on social media.

And I think just like all things mental health related, there's a spectrum. Like not all of us are perfect focusers. 24 7 and not all of us have severe ADHD. What are your thoughts on that self diagnosing aspect and even just like the huge rise of diagnoses? Is it people are just more aware and actually getting diagnosed?

Or is it you just maybe are not the best at focusing and this is not an ADHD problem?

Dr. Nissen: Yeah, it's a, it's a super juicy question. And actually amongst my, , psychiatrist friends, some of us sort of feel like I need to push back and be like, you know, is ADHD just created by sort of the economy and this drive for like increased productivity and like, should we be more accepting and willing that, Hey, like we're, you know, we're just, , kind dumb, People that like kind of do some things right sometimes and are very inefficient other times and like grow in our acceptance of that.

And I think there is something to be said of that. That, you know, humans can strive towards too much sort of robot like efficiency or perfectionism. And that we should accept a little bit more our dumbness or our lack of, efficiency. , so that being said, , the, it is extremely difficult in the United States to get evaluated for ADHD.

the, , Diagnosis is often made by a child and adolescent psychiatrist, of which there's an enormous scarcity in many parts of the country. It's impossible to see a child and adolescent psychiatrist, and of those that are out there, also a lot of them don't accept insurance. And so then there's an issue of accessibility based on, you know, economic means.

, and, , so, they would be one group of clinicians that would be able to do a diagnosis. But another, , , sort of a, a required standard for people that are getting like academic accommodations, , , you know, extra time on tests and things like that is to get a neuropsychological evaluation, which is, , a several hour long evaluation by a neuropsychologist, which is a subset of, of clinical psychologists.

Who charged thousands of dollars for these evaluations. And so again, it's not only are they few and far between, but also, you know, not accessible to everyone. So I think there are a lot of people across the country that maybe really did struggle academically their whole lives. , and they didn't have the resources or, the means or, or know anyone around them that could evaluate them for ADHD.

Or they just didn't know about ADHD. , the other thing I would say is that. You know, Sometimes, people find it very helpful to have a clear diagnosis. And sometimes people, are able to say, Well, who cares whether or not I have it or whether or not I have a diagnosis? Like, let's just figure out how to make me sort of better at focusing, , and more effective.

, and I would say certainly for anyone out there, That, , whether or not you have ADHD, if you are having problems with your performance in school or, , or professionally, then the things that we're going to talk about today will be helpful for you. So, , in many ways, CBT for ADHD, cognitive behavioral therapy for ADHD, or executive function coaching is something that kind of all of us need.

A lot of people say it's sort of like, you know, adulting 101, but it's true. , so, , yeah, I guess sort of it's a, it's a long winded answer to your question, but I would say that, , yes, there are probably people that have undiagnosed ADHD. Yes. There's probably people that, are just sort of following the tick tock trend and they think.

have it too, but they probably don't. And the main distinction between those groups of people would be, , whether or not they had these symptoms from a early age and that were consistent across different, , atmospheres or different, , scenarios. So these symptoms were present both at school and at home.

And then also whether or not you can rule out that they had other things going on. So it definitely wasn't due to depression, it wasn't due to, like I mentioned before, a thyroid issue or anemia or another medical problem like that, sleep apnea also. , , yeah. that it's significant enough to cause impairment across those areas.

Sadie: Yeah, it's, it's really interesting. I'm excited to dive into all of the behavioral shifts you can make because when we think about Like the context of COVID and how much we're now relying on technology and academic and workplace settings and how distracting that can be and also What our interactions with social media look like now versus even five years ago Like things are much more engaging and at a much faster pace.

And so it makes sense that with all of those distractions and with how our attention spans have responded, that maybe it feels harder to focus than it did five years ago. Or maybe the environment looks different and you don't necessarily have the skills that transfer over. And so I think that's another piece of the puzzle that I think universally, it, it, it It can be, , a relatable experience.

But before we dive into all the things people can do, I think another really interesting piece of this puzzle is over medication. And there was all the news headlines about Adderall shortages and a bunch of studies that have been done with regard to lupus. adolescent prescriptions, , of stimulants.

And so, so many schools of thoughts here. But what is your perspective on stimulants for ADHD and potentially over prescribing them to kids and young adults?

Dr. Nissen: Yeah, so stimulant medications are typically the treatment for ADHD, both in children and adults. So these would be medications like Adderall, Ritalin.

There's a lot of new versions of these medications. Focalin, Concerta, Adderall, XR. There's a lot of these brands out there. And these medications, when you look at the effect size, so how effective , And the kind of how, , how big of a chunk of, , people you could expect to improve , , , with these medications, , they're amongst the most effective medications that we have in psychiatry and also, , in, in medicine generally, the effect sizes comparably are really good.

So, , it really helps to add a stimulant for people that have true ADHD. There are two major sort of, , classes, , and so one is amphetamine based and one is methylphenidate based. Amphetamine, , base are the Adderall and Adderall type of, , medications. , so Adderall, XR, Vyvanse is sort of a relative as well.

, and then, , the methylphenidate medications are Ritalin. Focalin, , and several of these other medications. The, the , amphetamine based ones increase dopamine and norepinephrine, which are two neurotransmitters. They increase them more in the synapse. So these are kind of like stronger stimulant medications.

Adderall is, is a stronger stimulant medication. Methylphenidate, increases dopamine and norepinephrine a little less, so, methylphenidate or Ritalin is a little bit, , of a, like a lighter version of Adderall, even though, you know, the outcomes are pretty similar, , So, , there are some cons some significant concerns with these medications.

, I personally, you know, would definitely think twice about using them, for myself or for any loved one or for any of my patients. In fact, I very rarely prescribe them. , and that is for a couple different reasons. First of all, , these medications are known to have addictive properties. , So, , th for this reason, they're Schedule II, so they're controlled substances, which means that, , You have to work very closely with your prescriber to, , to get these prescribed to you and, , you know, you can't just get, , one prescription with a million refills and you're all set.

You need to check in with them regularly to make sure that you're not having, you know, , , an addiction or, , a dependency to develop. , also as part of that, your body can, , become, , accustomed to, to the medication. Tolerance is what it's called. Meaning that you, , if you don't take breaks. , one weekend or two weekend days to sort of have your system reset, then you're going to keep needing more and more to have the effect.

So because they're controlled substances, there's a lot of logistical challenges related to that. You mentioned the, the shortages. , those are a huge pain in the butt, , for both patients and for prescribers because there is a shortage I think is, is first adderall, , is critical. Then people had to prescribe other stimulants to sort of replace those.

So then it led to shortages of all other sorts of stimulants. , and so then that meant that patients were calling around to all these different pharmacies, trying to see what they had in stock, and pharmacies were overwhelmed. , and to some, to some extent, it's still happening right now. It's been going on for over a year and a half now.

, so that's one thing for people to think about. It's like, do you really want a medication where there's going to be this much each month to, you know, get it refilled? the second thing I would say is that, , there are concerns around physical health. So, stimulants are known to increase your, cardiovascular, , , measures.

So increase your heart rate and your blood pressure. For a long time, it hasn't been known whether or not that has any long term risk, but there was a recent study that was published By Zhang and colleagues that showed that there was an association between long term stimulant use and cardiovascular events Heart attack stroke things things like that.

And so certainly especially in the adult population or even in the kids population where you would be taking this for a long period of time, that's something you want to think about. So for any of my patients that I do prescribe stimulants, I say, you know, this really should be a temporary measure until we can get your executive functioning to top notch and then we can get rid of this stuff.

, so that's one thing to consider. The other thing is there's, for a long time, there have been animal studies that show there's maybe some, you know, Neurotoxicity, some, some toxicity to neurons and that there could possibly be some areas of the brain that are damaged by use of stimulants. , and, You know, there's many, there's, there's other side effects that are worth considering.

People, if they were, , genetically predisposed to psychosis or schizophrenia, for example, stimulants, especially amphetamine based stimulants like Adderall, could have some risk of triggering, , psychosis or a manic episode in somebody with bipolar disorder. , genetic predisposition, insomnia is a common side effect and problem.

, , so there's, there's many things that are worth considering. , downsides to these medications, even though, like I mentioned at the beginning, they, , have good effect sizes and can be very helpful for people.

Sadie: Yeah. So, executive functioning and behavioral shifts that you can make to improve attention and focus and just, like, general functioning when it comes to completing tasks and staying engaged.

Talk to me about what that looks like. does executive functioning like fall under the umbrella of CBT? Are you pulling from different modalities? What do you recommend that patients implement?

Dr. Nissen: Yeah, so there are a few evidence based, I like to call them psychosocial interventions. These are medication free interventions that can be helpful for ADHD with randomized controlled trials backing them up.

So one is CBT for ADHD, that's cognitive behavioral therapy for ADHD. Another one is Executive Function Coaching. actually, Executive Function Coaching doesn't have as strong of an evidence base, but, , I'll talk about some of the similarities here in a little bit. Another one is Cognitive Remediation or Cognitive Training.

It's done by psychologists. and then the final one that I'd say is Mindfulness Based Cognitive Therapy. So the first three that I mentioned have some similarities and overlaps. These are different forms of psychological support, , often delivered by a therapist or a psychiatrist that are focused around a few different major executive functions.

, the most common ones calendar management. So this is making sure, first of all, you have a calendar. Second of all, that you're practicing good calendar hygiene. So this is something I check in with people on their appointments is, , do you have both formal commitments and informal commitments on your calendar?

So you can see, Hey, I told somebody I was going to meet with them for lunch at 1 PM, but then now I say I also have a meeting scheduled for 1 PM. , I signed up to go to this conference on, , you know, a month from now, but now I'm just realizing that one of the nights is actually my anniversary. You know, something like that, , does it have built in, , transition times?

So things like if you have one meeting here and then another one, , across town, you can't have them back to back. , you need to build in your time to get from one to the other. And then having notifications on or a way to know that. And then also an important part of the calendar hygiene is checking at least twice daily.

So practicing with people, checking in the morning and checking in the evening. before the end of the day. , and in the evening you're checking what's coming up the next day, so you can see that. As part of that, I like to do with people something that's called memetic processing, which is like a visualization exercise where we literally close our eyes and we imagine ourselves going through every part of the day.

And as you're doing that, you're, you're picturing yourself putting on the clothes and then you're picturing yourself for me, you know, going into the clinic and then saying for a patient, you can sort of, , see how things are going to go . From one thing to the next, you prepare yourself and then you might recognize where there's errors where you're like, oh crap, I was thinking, I have this thing at four o'clock, but like, it's way over there and and my thing before it always takes up the whole hour, how am I going to get there in time?

And so you can see those, those errors beforehand. So that's calendar management. It's one of the themes across these different approaches. Another would be task list management. So to do lists. , there's a whole system. To do this, and usually with people, I recommend having a general list that's subcategorized into different sort of spheres of life, then having a daily to do list.

And you, as part of this, you practice prioritization skills, which for that, I, with people, I use what's called the Eisenhower Matrix. This is, , a matrix that I think was made popular by President Eisenhower, , that is organizing things based on how urgent and important they are. If it's both urgent and important, you do it today.

You put it on your today to do list. If it is important but not urgent, then you need to put it on your calendar. You need to schedule it. this is something that like everyone with ADHD, , needs to learn, , because for everyone with ADHD, , there's this issue of like, there's, there's all these things that I need to do, but it's not urgent.

So I never do it. And so you need to develop this ability to identify those things and then put it on your calendar. And as long as you have a calendar that you're following, then you can do that. , So anyways, that's task list management.

Sadie: Do you have different platforms that you like people to use for tasks and to do lists?

Dr. Nissen: Yeah, I do. , usually I have a, I have a bit of a bias towards the Google workspace because, , usually if people, most people have a Gmail and so then, , if you have a Gmail, then you have Google Calendar. And then I like to use Google Keep. Google Keep has really good, , , It's it's good for to do lists.

, you know, people experiment with other ones, which is fine. , , there could be problems with integration and with, , you know, being able to update it both on your laptop and on your phone or whatever. , but as long as they're able to do that, that's fine. I have some patients and, , clients who, Who prefer to, , do things manually or keep, you know, , a physical calendar or, , to do list with them.

And that's fine as long, I tell them like it, it must be portable though. You need to have it with you so that, you know, if you, , are away from your office that you can, stay on top of these things. Otherwise, their papers multiply. And so everyone with ADHD will say, well, I already know these things. Like I've already tried this a million times, right?

And I tell people it's like going to the gym. Like you, you're never done, you know, you're never like, okay, now I'm fit. done with that. Check that off. Like, no, you need to, if you're going to be fit, you need to be fit every day. And it's the same thing with good executive functioning.

You're going to fail. You're going to have a million calendars. You're going to make a million mistakes, but if you follow this systematically and you work with somebody, you will develop these skills and not that long of a time. Like usually with people that are working with me intensively, it's, it's less than two months in order to really get this all pretty much sorted out.

So, , yeah, Those are two things. And there's other things about sort of minimizing , distractions in the workplace. There's different, , technological supports that people can use, like reading tools. , there's Swiftread, there's Bionic Reader. These are different sort of reading supports that help to hold focus while people are reading large pieces of text.

There's things like, , binaural beats and sound machines that do have evidence. , so there's there's , There's many sort of non medication, tools that people can use.

Sadie: I'm gonna get my to do list I can show you we can do show and tell because i'm very type a and to my knowledge Not adhd and I think I take it too far in the other direction.

Am crazy with my calendar and I've been doing this for years So it's not just like a weekly phase where i'm like, oh i'll be really organized and insane with this it somehow is maintained But I have my google calendars that I integrate all of them onto my apple calendar so I have Literally eight gmails from like school and work and other work and the podcast and so it all has to be on one So I have like my 16 integrated calendars color code and I do what you're talking about where it's like informal informal commitments And things I might do that.

I want to kind of be aware of when those need to be blocked off and then I have Asana, which is incredible. And this, I have every class and then work commitment color coded, and these are all the things I didn't do yesterday.

But I, like, organize all deliverables and deadlines on there, which works really well. And then, where it gets crazy, is that I have my bullet journal, which, I don't know if you've ever worked with anyone that does bullet journaling, but it's a whole other crazy side of scheduling.

And I do, like, my, weekly calendar. And then, I also have my daily to do lists.

Dr. Nissen: Look at that. So, clearly

Sadie: I'm very reinforced by checking things off. But, it helps to not forget things and to have everything organized and on all the places at all times.

Dr. Nissen: Absolutely. Yeah, you have, anyone that's looking, you're seeing some A executive functioning skills right there.

Maybe

Sadie: too much.

Dr. Nissen: Yeah, no, I mean, well, it is something to think about, you know, and that, that is, I've had, , I've had patients that are the other side, and I treat things other than ADHD, but people that have, , you, you don't, I'm not saying you have these things, but people do out there have obsessive compulsive personality disorder or OCD, , obsessive compulsive disorder, where, you know, then there's a challenge of tolerating a bit of imperfections, a bit of, , breaking rules, , and doing exposures to that.

And it goes back to what we were talking about before of like this, you know, is, is ADHD real? And, and do we just not have tolerance enough in society for sort of imperfections and inefficiency? So it's a balance, I think, for sure. But. Those, those sort of systems that you have are exactly what's needed, you know, to have good executive functioning and, , probably to, do well on the things that are important to you.

, so I think, for people out there that have ADHD, that might seem, it might seem like a huge leap to get to wherever they are now, which is probably nothing or a million like dead, like zombie calendars out there. Yeah. , to getting to where you are, but I think there's also, there's a lot of intermediate steps and for people, you know, I had one patient who's a writer.

And so he, he's a writer and he does some, , like tutoring on the side. And so he really only has like one formal commitment. Like he has two or three meetings for tutoring during the week. The rest of his time is completely open. And so putting structure and actually creating a calendar in the first was an important first step.

, and Even with great executive functioning his calendar, you know looks a lot simpler than yours does So there's a whole sort of gradient for the people can exist out there I will say I do give myself a lot of grace like I write the tasks down so I don't have to remember them which helps a lot with mental stress and saving yourself work being like am I supposed to be somewhere like I have this recording like that helps and then i'm always like well Tomorrow, it'll happen at some point.

Sadie: But I, I wonder if this is a piece of the puzzle as well, which is willpower. And if you've written down the things or it's that idea of like, it's important but not urgent. How do you help people get out of that kind of mental block where it doesn't need to be done, but it should be done and it could save you stress down the line?

How do you kind of like bridge that gap between intention and action, , with regard to focus and tasks.

Dr. Nissen: That's a, that's a really great question. The answer would be that it's a motivation question. So we're talking about things that are important and not urgent. And so if you don't want to do something or it's not really getting done, you need to ask yourself, is it important and, or is it urgent?

If it's not important and it's not urgent, But it's not important, then you need to delete it. A lot of people have these zombie to do lists that have, you know, these things on there that are like, read the book about, the history of, like, human civilization. and it's like, okay, it's not urgent, and, you know, if you're, that's not your career area, it's probably not important either.

So delete it. you shouldn't be holding on to all this guilt about not doing that and it being one of a hundred things that you haven't been able to check off. You need to get rid of it. So what's really important is identifying the things that are not truly important and not truly urgent and deleting them.

But for the things that are important, but they're not urgent, like we said, those need to be scheduled. So for example, for me, I did , this training in early identification of, , cognitive decline and reversal, , sort of protocols for that. It was a part of my professional development that I didn't need to do per se.

, and it was definitely not urgent, but I wanted to, and like, , it was important to me. So, I scheduled time each week. I made it through the modules and the testing and stuff in order to do that. So I think a lot of people have things like that. And so, you know, if you're still struggling with something, even though you do think like, yeah, this is something I want to do for my professional development or for my own development, but I'm still procrastinating.

I'd say the first thing is recognizing that procrastination is very normal in ADHD. I like to tell people that procrastination is their own self medicating of a stimulant, which is that when you are procrastinating and you're down to the crunch, you are definitely stimulated. you're giving yourself a huge bump of norepinephrine, which is one of the components of stimulant, , medications, the impacts on the synapse.

So, you're doing self medicating by doing that, and you, you'll probably see you are able to hyperfocus when you're, you know, put in that stressful situation. So that's normal. , , one thing is breaking down tasks and putting, , , early deadlines to things is very important.

So, you know, instead of, , , I'm going to finish this 10 page paper, a month from now to instead say, okay, I'm going to do on

Sadie: Monday. Oh, there you go. I only have sources.

Dr. Nissen: Well, that's great. That's great. So now you're going to get it. You're going to get some stimulant here. Come on. Some natural stimulant coming in.

Literally. You're going to laser focus. , but so for people to instead for ADHD, people need like extremely aggressive, , tight deadlines. So to say like, okay, we're going to set a timer right now for 45 minutes and you're going to write the entire introduction, 45 minutes, boom. You want to set extremely aggressive timelines, ones that maybe you won't even achieve, and that's okay, but you're trying to create this pinch for you with a, a bite size of the work that you need to do, and another thing is it with it being a small ask of, okay, it's only the introduction.

I can write that in 45 minutes. , The, the great thing is that it was something that's known in behavioral psychology is that it once you get started, it's easier to keep going. So oftentimes, I'll do that with people, but then at 45 minutes, they just want to keep going, , and they get a lot of it done.

So that's something to definitely use. But the other thing is oftentimes people, if they're procrastinating or they're not doing things that they, that are important to them, then it's a matter of motivation. And that's something to, visit with them. And so there's a thing called motivational interviewing that I do with people.

And so I'll say, okay, you know, , you said that you were going to, , , work out, this last week. And, , and it was scheduled in for you to do it at, 3 PM. And looking back on your week, it doesn't look like you did it at all. , so, do you not want to do it? Like, you could say for example, is it really worth it to do it?

are there other things that are better uses of your time than working out? So by challenging it, instead of saying like, you should be working out, we're saying, well, maybe you shouldn't be working out. What we're doing is we're giving you an opportunity to instead convince me rather than me convince you.

That's, that's what's happening in motivational interviewing. And so the person starts saying, no, like I do, I do want to work. I, I know, , I should. And this is something that's used in addictions as well. , you know, why don't you keep drinking? Why don't, why don't you drink more? , you use these sort of extreme examples . So yeah, so motivational interviewing , is something that's, that's very important in order to boost motivation once it starts to go, down.

Sadie: Yeah. And then you mentioned earlier that there are different techniques you can use to improve focus. Obviously one thing is like getting started on a small piece of a task and then it's easier to just maintain rather than motivate to do the whole thing.

Are there other ways that people can help improve their focus? If that's a barrier to getting these things done and, and sticking with a task.

Dr. Nissen: Absolutely. , so, oftentimes people need stimulation as a part of their, , , they need more stimulation in order to focus and get things done. One way to do that is by using what I call artificial procrastination or these tight deadlines that people can do in order to really feel the pinch.

Thank you. And get things done. And they do that by breaking it into a smaller task. Another thing is oftentimes people find that they need higher beats per minute music. , so instrumental music, , is less likely to cause a distraction and having it be upbeat, , can make the person feel a little bit more stimulated, a little bit more active.

, and then we want to eliminate distractions. So like. Number one thing for people is to take your phone and put it either in another room or put it in a drawer, make sure notifications off, that it's silenced, things like that. , sometimes people need to, , either X out of all of their open windows or, or minimize one of those and open a new window.

That's only with the thing that they're working on in order to decrease. Those distractions, , , making sure that there's no notifications for, you know, some of those, those common pop ups on computers. So like iMessage or WhatsApp, things like that, that, you're not having any dings on your computer as you're, as you're doing that.

So those, yeah, those would be some, of the common examples.

Sadie: And then one other question for people who are listening and they want to continue to improve their executive functioning skills, continue to adjust these behaviors, do you have any other recommendations for podcasts or books or resources, , where they can continue to learn about these things and kind of build their skill set, , around content?

Coping with and navigating ADHD, , in more of like a holistic way.

Dr. Nissen: Absolutely. , There's a number of different kind of get, get things done, , sort of books and tools and manuals out there. , One is called Get Things Done. , , one, , there's a bullet, , , notebook that you were just mentioning. , there's, , , atomic habits, and there's several, , you know, materials around that are out there that people use.

, so people can definitely experiment with those. I do find though that, oftentimes people with ADHD, they need someone coaching them through this. with ADHD you don't necessarily need ideas, what you need is accountability and implementation. , and so it's really helpful to work with somebody for that.

So, , that's the work that I do in my clinic. My clinic is Nissen Clinic. N I S S E N C L I N I C dot com. , Otherwise, there's other, , folks out there, you know, either, if you were just looking for a medication to try, then you would want to look for a psychiatrist. , if you are looking for more of these skills, you could look for an executive functioning coach.

, there's several, places out there where you can look for those. there is, , one that I, , recommend sometimes to people, relatively new, it's called Shimmer, and they do, , executive function coaching. , but, , certainly though, if you're looking for someone to, , maybe prescribe and do these things, then we're kind of a small community.

, so that, that's the kind of work that I do. , I would say some of the, other things that could be brought up or focused with whoever you're working with is there's some dietary interventions that have, a good evidence base, they have randomized controlled trials, , and then there's also some supplements that I use as well and non stimulant medications, , that I use.

So, , you know, some things like that. I think often paired with these lifestyle changes can create biggest shift. I didn't mention exercise yet, but exercises should be very helpful for people with ADHD and a lot of folks have ADHD symptoms that worsen in college because they're no longer on their team sports that they were doing in high school.

, so that's also very common. So yeah, I would say, , you can kind of string together some of these resources on your own, or what I do in my clinic is I try to put them all together.

Sadie: My last question is going to be if you could like wave a magic wand and give someone daily habits they were implementing that are really conducive to helping support ADHD, whether it's exercising in the morning versus at night or making sure a certain food group is, , implemented every day, , or, you know, Being, outside of the house when working, like, what would those daily habits be?

Dr. Nissen: first of all, you know, , waking up, I do have bit of a bias towards exercising in the morning versus later in the day, just because as part of just if you're trying to form a habit, , you'd want to minimize the chances for something to conflict with that habit.

So doing it first thing in the day is helpful. And certainly if you're doing as part of an ADHD regimen and you just want to make sure that it happens, then you'd want to do it first. So I would say you would wake up, you'd exercise, and then you would check your calendar, , and review your calendar for the day.

You would do some memetic processing. So like visualizing yourself going through the day. You would, , , appointments, you would set up a, you know, a good work environment, , that's where you minimize distractions. You have your phone with notifications off, your computer with notifications off on any messaging.

, and you'd have a separate window for whatever you're working on. And early in the day, probably for people that are taking medications or supplements, that would be a time to do that. So, one of the, , non stimulant medications might be something that would come in at that point.

, or a supplement, , dietary wise, there's not, necessarily something to add that would have a huge, , benefit, but, , usually people that are working with me that want to do a dietary approach, there'd be a form of an elimination diet in order to remove possible, allergens from their, their diet that could be impacting their ability to focus.

, and it would be a lower carbohydrate diet as well to avoid some sort of, , like brain fog or that like 2 PM, , brain fog that you have if you have a big bowl of pasta for lunch. , but then, you know, ending the day with checking your calendar again, , and then, you know, going to bed and getting good, high quality sleep would definitely be a part of it as well.

Sadie: Amazing. Well, if people want to continue to follow along with your work or reach out to potentially work with you, where can people find you?

Dr. Nissen: Absolutely. So my, , probably the best spot would be my clinic, which is nissenclinic. com. N I S S E N C L I N I C dot com. And then otherwise, I'm on Instagram at drnissen, D R dot N I S S E N.

Sadie: Amazing. I'll put that in the show notes. And thank you again so much for joining me.

Dr. Nissen: Of course. Thank you so much for having me, Sadie.

Sadie: Thank you so much for listening to this week's episode of she persisted. If you enjoyed, make sure to share with a friend or family member, it really helps out the podcast. And if you haven't already leave a review on apple podcasts or Spotify, you can also make sure to follow along at actually persisted podcast on both Instagram and Tik TOK, and check out all the bonus resources, content and information on my website.

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