by Dr. David Teplin, Clinical Psychologist
The following was derived from a presentation given by Dr. David Teplin for the 2010 ADHD Awareness Week
ADHD is a highly genetic neurological disorder. However, its impact on functioning can create significant psychological effects. Thus, when we talk of treatment and interventions, we need to emphasize an integrated approach, including that of psychotropic medication, as well as a combination of psychological interventions.
Although the focus of this article is on the psychological interventions of adult ADHD, it would be remiss of me if I did not acknowledge the useful and helpful role that psychotropic medication (in particular, stimulant medication) can play for many in the treatment of adult ADHD.
Of course, such medication is not a panacea either. In fact, among those with adult ADHD, drug therapy alone is often insufficient. Current literature suggests that it is insufficient for over half of the adult ADHD population. As such, this is yet another reason why we need to emphasize an integrated treatment approach with respect to adult ADHD.
Having said that, it is really essential that we recognize that even with the identical diagnosis, and the identical treatment regimen, no two adult ADHD patients look, present or respond to treatment in the identical manner. For that reason alone, an individualized treatment plan must be always be emphasized.
This is especially important as only about a third of adult ADHD patients have what we call pure ADHD and no other co-existing psychiatric disorders. Two thirds, however, have co-existing psychiatric disorders, often including various forms of depression, anxiety, addictions (e.g., alcohol, drugs, gambling, sex), insomnia, eating disturbance, and personality disorders (particularly Borderline and Antisocial Personality Disorders).
While there are clearly several forms of psychological interventions, perhaps the one that has been most studied over the past number of years is Cognitive-Behaviour Therapy (CBT). Here, the term, “cognitive” refers to one’s thinking, attitudes, or beliefs. Those may involve either the present and/or those that are more longstanding from childhood. In traditional CBT, one looks at the person’s automatic thoughts, the nature of those, and how those impact how the person then feels and acts.
In another form of CBT, one looks at the person’s longstanding schema’s or core beliefs about him/herself, others, the world, as well how those influence the person’s coping and problem solving styles. Of course, over time, those become quite reinforced and maintained. In adults with ADHD this is particularly apparent as many have experienced a lifetime of difficulties, often feeling like failures, defective, incompetent, inadequate and socially undesirable. These, in turn, lead to low self-esteem, poor self-image, and self-doubt.
CBT has been shown to be rather effective in the treatment of Mood Disorders, Anxiety Disorders, Substance Use Disorders, Eating Disorders, Pathological Gambling, Primary Insomnia, adult ADHD, and Personality Disorders. This becomes especially important because, as already mentioned, many adults with ADHD have one or more such overlapping disorders, and which also requires psychotherapeutic treatment.
When we use CBT in everyday clinical practice for the treatment of adult ADHD, in many instances it is not traditional CBT. One may need to modify some aspects of traditional CBT because not everyone with adult ADHD can tolerate more traditional forms of therapy, such as exploring one’s longstanding schema’s and core beliefs.
One of the other reasons why CBT may not be suited for everyone with adult ADHD is that traditional CBT relies a lot on things like homework assignments, keeping logs, etc., and for some adults with ADHD it is just too difficult. Some may be non-compliant, not necessarily in an oppositional manner, but due to either difficulty keeping focused, or remembering to bring in the homework from the last session.
With respect to CBT, often times we are also looking to give the adult ADHD patient some day-to-day practical skills because in many ways, untreated and unmanaged, we know that this is a serious impairing disorder. Such impairment is on a continuum, and can impact one’s academic setting, work setting, occupational setting, as well as relationships with partners, family and friends, as well as one’s ability to parent.
This is where the behavioural aspects of CBT can be so important, practical, and beneficial for adult ADHD patients. Under the behavioural umbrella would include social skills training, anger management, relapse prevention, coping skills, problem solving skills, time management skills, organizational skills, and learning how to both deal with, and better manage, one’s problems with procrastination.
Relapse prevention may be particularly beneficial for those adults with ADHD who also have co-existing problems with substance use, gambling, eating, and/or sex. Such an intervention is geared toward teaching patients a wide range of cognitive and behavioural coping skills to avoid or deal with a brief return to such problems, or a full-blown return to previous levels of such problems, following a period of abstinence. Of particular importance here is to help patients recognize their various high-risk situations that can lead to potential problems, and do something about them.
Anger management issues often centre around low frustration tolerance, temper outbursts, and being easily angered. Again, this too, highlights adult ADHD as having to do with deficits in the frontal lobe with respect to executive functioning (i.e., self-control and self-regulation).
Of course, anger control problems can also be readily witnessed in persons with other diagnoses besides adult ADHD. For example, persons with a mood disorder, an anxiety disorder, a substance use disorder, or a personality disorder can also be rather aggressive, irritable, explosive, agitated, and highly volatile.
Social skills training is a big piece with respect to the behavioural aspects of CBT. Adults with ADHD can be really good and really skilled at reading into nuances and feelings of other people, but at the same time, may have limited insight into their own behaviour, or how their ADHD related behaviour impacts other people around them. In particular, many adults with ADHD misread social cues, and many also have a tendency to blame others rather taking responsibility for their own behaviour.
Another form of treatment that can be helpful for the adult with ADHD is couples therapy. This form of therapy may also need some modification from a more traditional approach to such work for those with adult ADHD. One of the issues here is that if one or both of the couple has adult ADHD, it becomes important to sort out what is specifically ADHD-related that such couples have to face, versus what is “garden variety” dynamics and issues between couples; period.
Having a diagnosis of adult ADHD diagnosis does not mean that the condition is responsible for every aspect of a person’s life. Like others in the general population, the adult with ADHD may also benefit from addressing personal growth issues, or dealing with certain lifespan issues or life events in psychotherapy.
Psycho-education is also key in the treatment of adult ADHD. Patients with adult ADHD should be strongly encouraged to educate themselves as much as they can on their condition. These days there are several sources that are readily available, including workbooks, articles, magazines (e.g., ADDitude), workshops, virtual conferences, as well as webinars and podcasts via the Internet. In addition, there are also adult ADHD associations that provide several resources for their members.
Finally, family therapy may also be of benefit for some adult ADHD patients and their families. Of course, we know that genetics plays a huge role in ADHD, and as such, ADHD runs in families. Thus, either one or both parents may have ADHD, as well as one of more of their children, too.
However, this is highly individualized, and therefore for some families, this may or may not be contra-indicated. In some cases, it may also be difficult to tease out whether such familial issues and dynamics are systemic in nature, related to the impact those members with ADHD may have on the family unit as a whole, or due to a combination of such factors.
In conclusion, untreated and unmanaged, adult ADHD remains a serious impairing disorder.
Dr. David Teplin is: a Licensed Clinical Psychologist; Adjunct Professor at Yorkville University-Faculty of Behavioural Sciences; a member of the Professional Advisory Board of the Attention Deficit Disorder Association and the Editorial Review Board of the Journal of Attentional Disorders. Dr. Teplin is also a member of the AbilTo board of advisors.
