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 presentation is on the psychological interventions for adult ADHD, it would be remiss of me if I did not acknowledge the useful and helpful role that psychotropic medication, and in particular, stimulant medication, can play for many in the treatment of adult ADHD. Research suggests that about three-quarters of adults with ADHD respond to stimulant medication.
Of course, medication is not a panacea either, and does not target all aspects of the disorder. As such, we need to emphasize an integrated treatment approach with respect to adult ADHD. It is 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.
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 those adults with ADHD some day-to-day practical skills because in many ways, untreated and unmanaged, ADHD remains a serious impairing disorder. Of course, such impairment is on a continuum, and can vary considerably from one adult with ADHD to another. Thus, key areas in one’s life are quite commonly negatively impacted, such as one’s academic, work or occupational setting, one’s intimate relationships, one’s relationships with family and friends, as well as parenthood.
This is where the behavioural aspects of CBT can be so important, practical, and beneficial for adults with ADHD. In particular, they may benefit greatly from acquiring various behavioural techniques, strategies and interventions to address anger management, low frustration tolerance, road rage, poor time management, disorganization, procrastination, acting in the moment, blurting out hurtful or insensitive comments, personal space, and misreading social cues (whether verbal or non-verbal in nature),
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
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.
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, ADHD-related magazines, 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.