Beth Main's blog

Exercise and ADD: An Expert Interview With John J. Ratey, MD

I've always been an advocate of exercise in order to lessen ADHD symptoms.  Here is a terrific interview with Dr. John Ratey, published by  Medscape Psychiatry & Mental Health (www.medscape.com) on  10/08/2009.  It's long, but worth the read.

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Editor's Note: Attention-deficit disorder (ADD), also called attention-deficit/hyperactivity disorder (ADHD), is often surrounded by controversy over medication use and is perceived by many as a condition that is overtreated. John J. Ratey, MD, advocates that exercise should be included in the treatment regimen, and that exercise can even reduce or eliminate the need for medication. An Associate Clinical Professor of Psychiatry at Harvard Medical School, Cambridge, Massachusetts, Dr. Ratey is author of the book Spark: The Revolutionary New Science of Exercise and the Brain, as well as several related books in the popular press. He also has consulted on clinical studies pertaining to exercise and psychiatric conditions.

Medscape: Can you start with some background about ADD, and how exercise affects the brain?

Dr. Ratey: First, ADD affects at least 8%-10% of children, and almost as many adults. It's now considered a biological brain disorder and may have genetic components. There are 2 basic ways of thinking about ADD in relation to exercise: One is about the neurotransmitters norepinephrine and dopamine, both believed to be drivers of the attention system. Exercise increases the concentration of both dopamine and norepinephrine, as well as other brain chemicals. I have always said that a dose of exercise is like taking a bit of methylphenidate (Ritalin®) or amphetamine/dextroamphetamine (Adderall®); it's similar to taking a stimulant. Second, over time, exercise helps build up the machinery to increase the amount of neurotransmitters in the brain as well as their postsynaptic receptors. Chronic exercise eventually causes growth of the system. The more fit that you are, the better the system works.

Medscape: Where do these findings come from?

Dr. Ratey: Exercise has been one of the hot topics for the past 15 years in neuroscience. The initial studies on exercise and dopamine came out in the 1960s and 1970s. I'd like to add that exercise activates the frontal cortex in all age groups. Many ADD symptoms are related to the brain's executive functions, which are located in the frontal cortex.

Medscape: Are there studies looking specifically at exercise and ADD?

Dr. Ratey: There are numerous studies about dopamine and norepinephrine and exercise, but when it comes to ADD, clinical studies with exercise are just starting.

Medscape: What got you interested this area?

Dr. Ratey: I had several marathoners for patients who had stopped marathoning because of injuries. These particular patients first got depressed, and then some presented with ADD symptoms for the first time in their lives. This was back in the early 1980s, before we really thought much about ADD -- in kids or in adults.

Medscape: ADD isn't something that can just materialize later on in life, is it?

Dr. Ratey: No. In the case of the runners, they would have had ADD before, but their exercise regimens served to keep it under control. What's been observed over the past 30 years is that athletic people who played regular sports in high school went to college but stopped exercising, and then saw the first major signs of ADD. They may have had some hint of ADD in the past, but in college it came on like gangbusters.

Medscape: How do other people in psychiatry react to the idea of prescribing exercise?

Dr. Ratey: People are just beginning to pay attention to this. It was only 2 years ago that the American Medical Association (AMA) president, in his inaugural address, said that "exercise is medicine." He said that every physician, no matter their specialty, should ask every patient at every meeting about their exercise regimen and encourage them to pursue this. Neurology is paying more attention to exercise, with whole conferences looking specifically at exercise and Parkinson's disease, for instance. If exercise can help protect against some of the symptoms in Parkinson's disease, then it should also affect ADD, because the diseases have overlapping features.

Medscape: Is exercise starting to get respect as a treatment option?

Dr. Ratey: Yes. Historically, it started in cardiology studies. Then psychologists noted that the people in cardiac rehab were improving emotionally as well as physically. They looked at depression, anxiety, hostility, aggression, and stress in people who started an exercise regimen for cardiac protection or healing. Duke University researchers were leaders in measuring the effects of exercise on the emotional side. Exercise is now studied in practically every specialty.

Medscape: How often should patients with ADD exercise, and how intensely?

Dr. Ratey: There are a variety of exercise programs and regimens out there. Some schools have exercise breaks every hour or two, but other regimens may work, too. Someone with ADD could benefit from an exercise break of 10-15 minutes every hour or so. It helps everyone, not just patients with ADD.

Medscape: Does exercise need to be done several times daily?

Dr. Ratey: Yes, but it doesn't have to be for very long each time. Just enough to get the heart rate up for at least a few minutes. Benefits persist for a while after exercise. We know there are improvements with low levels of exercise, such as walking for 20 minutes. Of interest, a number of people at various companies, such as Merrill Lynch and Google, now have standing desks.

Medscape: Dr. James Levine, a researcher from the Mayo Clinic, mounted his desk on a treadmill so that he can walk while he works. Would walking while working help ADD?

Dr. Ratey: That's the Tread Desk and would be excellent for both adults and kids. It certainly has the potential to keep ADD in check.

Medscape: For Medscape readers, what advice should doctors give to patients?

Dr. Ratey: They should advise patients to exercise daily. Whatever medical treatment has begun, exercise needs to be included, too. It should be daily. Aerobic and strength training is fine. Balance training is important in patients with ADD and can be accomplished with yoga, tai chi, or balance exercises. Exercise needs to become a lifestyle, a habit.

Medscape: Would regular exercise affect the medication needs of patients with ADD?

Dr. Ratey: It often does. A number of the patients described in my book got off medication completely. In people who have trouble finding the right medication regimen, exercise can really help. The exercises chosen should be fun so that people will want to do them.

Medscape: Does exercise become a chronic medication?

Dr. Ratey: Yes. However, this isn't for everyone. There is a spectrum of severity in ADD. There are plenty of marathoners who still need medicine, but maybe they need less than they would if they didn't run. A number of superathletes have ADD. A prime example today is Olympic swimmer Michael Phelps who was diagnosed at the age of 9 and put on medicine. He found it impossible to stay still in school because of ADD. Then he began swimming. When he got up to 3 hours of daily exercise, he didn't need medication anymore. Many of these kids develop "learned helplessness syndrome." They've failed so much in the past that they now expect to fail. They get depressed, use drugs, or play video games all day. Exercise prevents people from getting into that. Animal studies have shown that exercise makes it tougher to develop learned helplessness.

Medscape: Isn't there a certain amount of positive reinforcement? If you're running from point A to point B, when you get to point B you've gotten there. You've achieved something.

Dr. Ratey: Yes; the effects on self-efficacy are huge. Although exercise helps balance brain chemistry, there are helpful incidental effects, such as self-efficacy.

Medscape: It sounds as if patients with ADD can't go wrong getting into an exercise habit.

Dr. Ratey: Them, and everyone else, although most patients with ADD will still need some medication. People can find out more from my Website www.johnratey.com.

Medscape: Thanks very much for your time today.

Interviewer: Pippa Wysong, Freelance Writer Interviewee:  John J. Ratey, MD, Clinical Associate Professor of Psychiatry, Harvard Medical School, Cambridge, Massachusetts Medscape Psychiatry & Mental Health © 2009 Medscape, LLC

Workshop: Introduction to Meditation and Yoga for People with ADHD

Are you looking for holistic options to help you manage your Attention Deficit / Hyperactivity Disorder?   Yoga and meditation are both excellent choices.  They can help you increase your attention span and self control, while decreasing restlessness and tension. I've teamed up with Tina Stroh and Ron Blouch, co-owners of the Just Plain Yoga Studio here in Camp Hill, to offer a two hour workshop on meditation, yoga, and ADHD.  If you are even mildly affected by ADHD-like symptoms, including distractibility, impulsivity, and/or hyperactivity (which usually manifests as restlessness in adults), you won’t want to miss this one. Here’s what you’ll learn:

  • How yoga and meditation can reduce ADHD symptoms
  • Meditation techniques designed specifically for people who have trouble concentrating
  • ADHD-friendly yoga techniques that can calm the mind and body to help improve your ability to focus
  • Success strategies for integrating yoga and meditation into your daily life

This introductory workshop is designed for adult beginners.  There are no prerequisites or advanced knowledge required.  You don’t even have to be able to sit still for very long.

Date:  Saturday October 10, 2009, 1:00 - 3:00 p.m.

Cost: $45 by October 2, $55 thereafter

Location:  Just Plain Yoga Studio, 1845 Market St. & 19th, Camp Hill, PA

Register online at www.justplainyoga.com  or call 717.975.YOGA

Give me a call if you have questions or would like more information.  I hope to see you there!

Take your coping strategies with you

I learned a valuable lesson on vacation the other week.  Even though it happened on vacation, it’s a lesson that applies to any journey away from home.  Here’s the story… Rhode Island was our destination.  None of us had ever been there before and we were excited about going to a new place.  Wanting to be spontaneous, we didn’t do much planning. On the first full day of our trip, we had donuts for breakfast.  What a treat!   We then spent the day exploring the area.  The roads were poorly marked and didn’t match the directions we pulled up on the mobile phone’s tiny browser screen.  We were chronically lost and incredibly frustrated.  I ordered what I wanted when we stopped for lunch: a cup of chowda and homemade white bread.  Yummy!  By dinner time, after getting lost a few more times, my brain was so overloaded that I had a great deal of difficulty coping with the unfamiliar grocery store.  I hadn’t made a shopping list, so I didn’t pick up anything with nutritional value. Can you spot my mistakes?  I did, but only after recovering from a complete meltdown.  Here they are:

  • Junk food.  Since I was on vacation, I felt justified in eating whatever I felt like.
  • No exercise.  Similarly, I abandoned my exercise regimen.  Not that I could have exercised much in the car during the 8-hour trip.  But I could have a found a way when we arrived.
  • Insufficient sleep.  Not having exercised, and being in a strange place, it was hard to sleep the first night.
  • No supplements.  I failed to unpack my supplements and put them next to the coffee filters (so I bump into them in the morning) like I do at home.
  • No printed maps.  My coping strategy to avoid getting lost is to print and review maps ahead of time.  Since we were being spontaneous, we didn’t do that.  Can you believe that not one of the 47 maps in my glove box included the state of Rhode Island?
  • No planning time.  I’m very good at planning when I take the time to do it.  When I don’t, I get overwhelmed by an unlimited array of choices.

All of this added up to a very unpleasant evening as my ADHD symptoms collided into one big emotional mess.  Thankfully, my son and my boyfriend were extremely patient and supportive.  Thanks guys!  I was able to regroup the next day and enjoy the rest of the trip. Don’t make the same mistake I did.  When you go away somewhere – whether it’s vacation, a weekend getaway, a business trip, or off to college -  remember to take your ADHD coping strategies with you.

Take it one step at a time - literally

“Take it one step at a time” is sound advice for anyone when things get overwhelming.  It’s especially helpful for those of us with ADHD.   If the whole project is too much to deal with, just identify the first step and focus on that.

I take this advice literally as a transitioning strategy.  When I’m lying on the couch watching TV or reading a book, and it’s time to go to bed, it’s almost impossible to get up.   Turning off the TV and making the arduous climb up all 14 stairs seems like way more than I can handle.  So I procrastinate. I know how important it is to get a good night’s sleep, though.  I really want to be able to focus tomorrow.  I won’t be able to do that without enough sleep.  So I do what any responsible person would do:  focus on my left foot. All I have to do is put that one foot flat on the ground, next to the couch. It takes every ounce of energy, but I can do that much.  Then I wait about 30 seconds to get used to this somewhat uncomfortable position.  Then I focus on my right foot.  I put it flat on the ground, next to my left foot. 

Do you realize how hard it is to lay on the couch with both of your feet flat on the floor?  Yes, it’s very hard.  It’s much easier to just sit up.  And once you’re sitting, with just a little more effort, you can be standing. Does this sound crazy?  Slightly ridiculous?  Maybe.  But it works for me every time.

Late night TV watching not your demon?  How about the internet?  I have one for that too:  Just click the “X”. Like the TV, it takes Herculean effort to resist the internet’s late night charm.  If I think about stopping my research and making that arduous climb up all 14 stairs, it’s just too much.  But I can focus on the little “X” in the upper right corner of my browser window.  I just have to click it, and like magic, the internet is gone.  And I can get some sleep.

Transitioning is hard for people with ADHD, especially when we’re hyperfocused and tired.  This strategy just might make it a little easier.

Closing the ADHD confidence gap

Someone said to me recently, "I can only imagine how your results will soar when your confidence rises to the level of your expertise." Confidence? Hm? I haven't thought of myself as lacking confidence for a long time. But he could be right.

There are still times when I procrastinate, or avoid doing something entirely, because of self doubt. For example calling a nationally renowned psychiatrist to introduce myself. Or  approaching the folks at ADDitude magazine about carrying my blog. I'm an expert in my field, with years of training and experience. I get accolades from nearly everyone I work with. How could I still be struggling with this? Confidence issues are so high school.

Hm, high school. Maybe that's the answer. I had severe undiagnosed ADHD (early '80s, rural Pennsylvania, we'd never heard of it). My nickname was "Dizzy" even though I had an IQ of... well I won't reveal that. My Mom was constantly asking me, "How can someone so smart be so STUPID?!?" Naturally I grew up believing I was completely inept.

Let's trace the confidence lifecycle of the typical ADHDer:

Infant: Doesn't do much besides eat, sleep, and poop. She's pretty confident she can handle those responsibilities.

Elementary school: Begins to take risks, begins to notice failures, begins to wonder why she's different than other kids.

Middle/high school: Hits the wall. "Other kids don't struggle like this, what's wrong with me?" If an ADHD diagnosis is made, now she has a label, probably an IEP, and maybe a behavior chart. If the disorder is not explained thoroughly and compassionately to her and everyone she interacts with, self esteem issues are compounded. But happily, when she starts getting the help she needs, her confidence improves.

College and early adulthood: Finds her niche, discovers something she excels at. Confidence soars. But early wounds may still lurk beneath the surface. How to improve confidence? I'm not a fan of avoiding the "f-word" (failure) to boost self esteem. There's huge pride in failing at something, trying again (perhaps repeatedly), and eventually succeeding. If you only do the easy stuff, you aren't going to feel very good about yourself in the long run. Here are some ways to boost your confidence as an ADHD adult:

* Set up situations where you can fail safely. A martial arts class, for example.

* Stretch. Do something that's just a little outside your comfort zone every day.

* Visualize your successes, past and future.

* Solicit and re-read testimonials and fan mail, even if they're from your mom.

* Fake it til you make it. Act like you're confident, and soon you will be.

* Dress the part. Wear clothes that make you feel powerful.

* Prepare. If it's information you need, get it. Practice.

Try some of these tips before going into situations that require confidence, such as public speaking. Also call on them to help you take the chances in life that will move you towards your goals.

Alternate your “shoulds” and “wants”

ADHD is a world of extremes.  Some days we can’t seem to do anything productive.  Other days we only allow ourselves to work on the things we should, at the expense of everything else.  Life becomes a drudgery.

There has to be a balance somewhere.  But how to achieve it?

Try alternating your “shoulds” and “wants”.  Whenever you accomplish a not-so-interesting task that needed to be done, reward yourself by working on something you want to do.  Something more fun.  Then choose another item from your “should” list and get that done.  And so on.  As long as you limit the duration of the fun stuff, you’ll probably get more done that way.   Rewards are a great way to motivate yourself.

A variation on this theme works if you’re trying to eat more healthy foods.  For example, I was dying for some apple pie the other day.  So I ate some carrots.  Then I ate the pie.  No, not the whole pie!  Just a small piece.  I ate less of it because I was full from the carrots.   And I ate the carrots because I knew they were the gateway to the pie.  A "should", then a "want".

A balanced life is like lasagna.  It’s all about layering.  If all the pasta was on the bottom, and all the sauce was on the top, it wouldn’t be very tasty.

My new blog at ADDitudeMag.com!

ADDitude magazine, one of the world's leading ADHD publications, has asked me to write a blog for their web site.  It's called "Works for Me" and is a mix of advice and personal experience from a coach's perspective.  Check it out!

Social faux pas

Everyone at the martial arts school I recently started attending is super nice and exceedingly patient.  The black belts cheerfully help the less experienced.  However, there is one particular black belt I’ve been terrified of ever since our introduction at my second class.  Not because she's dangerous (she is) but because I humiliated myself in front of her.

Towards the end of class that day, my brain was completely saturated.  I could not absorbs one more fact.  If you have ADHD, I know you know what I mean.  She introduced herself using what I later learned was her Korean title.  It had about 24 syllables (okay, maybe six).  I couldn’t begin to comprehend what she was saying.  I was finally able to mutter her name back to her after four or five embarrassing attempts.   Then I just looked at her blankly.  Didn’t even give her my name in return. 

On the way home, I thought, she must think I have severe brain damage. I’ll be she hopes to never have to work with me again.  I certainly didn’t want to work with her again. Well, we had to work together the other night. I was terrified.  I’m still slow to figure out what I’m supposed to be doing (you know, typical ADHD difficulty with multiple step instructions), but I was able to follow along pretty well.  She was smiling and patient, as if she had complete faith in me.  After class, she said to me, “I’m sorry, I should have introduced myself. I’m not sure we’ve met”. SHE DIDN’T REMEMBER! 

Oh, what relief! I’m not afraid of her any more. Lesson learned:  Sometimes what we perceive as a social faux pas is barely noticeable, or forgotten within five minutes.  It lives on in our own minds much longer than it needs to, mingling with faux pas past and becoming a gremlin that’s hard to tame.   The truth is, most people are too busy worrying about their own stuff to remember our minor mistakes.

Improve your focus with water

You know that water is essential to life.  But did you know that even mild dehydration impairs your ability to focus?  Estimates are that 75% of us are chronically dehydrated, so it's likely that this applies to you. Don't wait until you're thirsty to get a drink.  By that time, you're already mildly dehydrated.  Here are some other warning signs:

  • Headache
  • Fatigue
  • Dry mouth, throat, and/or lips
  • Dark urine
  • Heat intolerance
  • Lightheadedness or dizziness
  • If, when you pinch the skin on the back of your hand, it drops back slowly

Here are some easy ways to keep dehydration from affecting your focus:

  • Keep a large container of water, or a cooler, near your work area to increase the convenience factor
  • Bring a water bottle with you every time you get in the car. Finish it by the time you get to your destination.
  • Set a daily goal, and use a checklist to track the amount of water you consume.   You may be surprised at how little you're actually drinking.
  • Watch your caffeine intake, since caffeine actually dehydrates your body
  • Keep lemon or orange slices in the refrigerator and use them to add flavor to your water
  • Make getting a drink part of your break routine
  • In the winter, use a humidifier or set out bowls of water to decrease the amount of water you lose through your skin

I’m not suggesting that water can cure ADHD.  But staying well hydrated gives you one more way to fight it. I had one of the dreaded "brain shutdowns" in my martial arts class the other night.  I also had a headache, less energy than usual, and got lightheaded after a few strenuous drills.  Failed the skin pinch test.  Looking back on the day I realized that I had consumed very little water.  Was the brain shutdown a coincidence?  I don't think so.  I guarantee you I'll be well hydrated for the next class. I'll close with this question from comedian Lily Tomlin: The formula for water is H2O. Is the formula for an ice cube H2O squared?

Setting an example

My personal trainer is tough.

"Mom, have you seen your workout chart?"

"Yes, I moved it.  I got tired of looking at it on the refrigerator. (pause for a few seconds)  Oh.  Now I can't find it."

"That's what you get for moving something that has a home.  Now you have to do 40 pushups as a punishment".

Drats.  He's right.  Now not only do I have to do twice as many pushups, but I still have to find the dang chart.

I don't mind admitting that I was wrong and he was right... not so much, anyway.  But I do try to minimize it.  I'm supposed to be setting a good example here.  The kid is doing a fantastic job of using his checklist every day with no reminders, and here I am, putting things where they don't belong.  This is good incentive.

Uh oh.  Now I've been caught writing a blog post instead of doing pushups. Gotta go.

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