e-pearls newsletter, November 2009

Introduction

While researching ADHD recently, I came across a couple of papers that detailed some of the psychotherapeutic techniques that have been shown to be effective in clients with ADHD, and I thought I’d share them with you. As usual however, first some background.

ADHD: A Brief Overview

ADHD is a disorder comprised of the core symptoms of inattention and hyperactivity/impulsivity. A DSM-IV diagnosis requires at least 6/9 symptoms in one or both of these symptom categories, resulting in impairment of function. The symptoms must have been present for at least 6 months, they must be present in two or more settings (school, work, home), and they must have begun prior to age 7.

It is important to keep in mind that the home, school, &/or work environment, as well as I.Q., can mitigate the level of disability; some children with symptoms might not be significantly impaired, and may remain undiagnosed (which can make it more challenging to diagnose as an adult).

The most common type in childhood is the combined type (inattentive + hyperactive/impulsive), with a prevalence rate of 61%, followed by inattentive and hyperactive/impulsive subtypes at 30% and 9% respectively. In most studies, ADHD persists into adulthood in 50%-70% of cases. The only clinical feature that has been found to predict persistence of childhood ADHD into adulthood is the occurrence of a major depressive disorder in that child.

ADHD is a familial disorder with a multi-genic inheritance pattern; in other words, many genes are involved in ADHD, and it is necessary to inherit a certain number of them in order for the disorder to appear. For instance, if you have a parent with ADHD, your risk is >50%. Similarly, if you have a sibling, child, or identical twin with the disorder, your risk becomes 20%-25%, 31%-44%, and 80%-90%, respectively.

The only other major points I’ll make before going on to talk about psychotherapy in ADHD have to do with the co-occurrence of mood and substance use disorders (SUD). For every ten adults with a mood disorder, at least one will also have ADHD; for every ten adults that have ADHD, four will also have a mood disorder; and for every ten adults with ADHD, five will also have an anxiety disorder.

This is important to keep in mind, because if underlying ADHD is not recognized and treated, the mood disorder may be resistant to therapy. On the other hand, if the mood disorder is severe (e.g., MDD with suicidal ideation), it would be wise to focus on treating the mood disorder first, even if ADHD is also known to be present.

ADHD is an independent risk factor for SUD; in adolescents with ADHD, 15%-30% will have SUD. In adolescents with SUD, 40%-75% will also have ADHD. Smoking in an adolescent with ADHD increases the risk of future SUD to around 50%.

Why Psychotherapy?

It is now widely accepted that the combination of medication plus psychotherapy yields the best clinical outcome for the client. Keep in mind that although medications alone are frequently helpful (70%-90% show significant improvement; 50%-60% become symptom-free), statistically there may be as many as 30% that do not show significant improvement, and up to 50% that may have residual symptoms.

Furthermore, the improvement in core symptoms brought about by medication alone are not always put into action, so to speak, by the client; clearly, psychotherapists can help in this regard (i.e., helping the client turn symptomatic improvement into improved life functioning). In addition, people that are suffering from ADHD have a number of comorbid disorders for which psychotherapy is also beneficial.

Psychotherapeutic Approach in ADHD

At present, the literature supports a fairly structured, cognitive approach for the treatment of the core symptoms of ADHD, which is summarized below.

Psycho-education:

This is well-established as a useful starting point. Lifelong ADHD can engender a deep-rooted conviction of low self-esteem coupled with a fear of failure; these clients frequently are under-employed, may have received a label of “learning disability,” and have had to work twice as hard to accomplish the same goals as their peers (i.e., impaired working memory and underlying anxiety that occur in ADHD interfere with academic and job performances). Clients often see themselves as failures; learning that a treatable neuro-biological disorder accounts for their difficulties can help overcome this. Their sense of self and world-view may thus be de-pathologized.

Readiness for change:

Many clients with ADHD tend to believe that they can never change; having lived with ADHD for their whole lives, it’s easy to see how this belief may develop. They may see themselves as not needing to change, or being unable to change. This seems to be related to a combination of ambivalence, low self-esteem, and anxiety.

Therapeutic alliance:

It is important for the therapist to take a relatively active and directive stance in therapy with adults; this helps to keep sessions focused on the issues at hand (such as core symptom expression & new coping strategies to deal with them). It is also important to remember again that clients with ADHD have often experienced failure at school, work, and in their relationships; the therapy process may be perceived as yet something else to fail at.

Because of this, clients with ADHD may be especially sensitive to perceived criticism or disapproval from the therapist (such as when they forget or arrive late for an appointment). This sense of not “measuring up” may be enough to re-activate memories of past failures, self-criticism, and emotional distress. If not recognized and discussed in therapy, it might cause the client to drop out.

Cognitive modification:

Although ADHD is not caused by cognitive distortions or negative thoughts, many people with ADHD have automatic, negative thoughts in response to stressful situations. Stress causes anxiety, which further impairs working memory, thereby increasing the chance of failure. Before too long failure is expected; hence their tendency to engage in negative self-talk, resulting in magnification &/or over-generalization, for instance.

It is useful for the client to recognize how this pattern can lead to a number of negative effects on emotion, attention, self-esteem, behaviors, and performance. Helping the client come up with alternative perceptions and explanations results in a more positive and balanced world-view, allowing the client to make more effective use of coping skills and strategies. Cognitive modification also fosters a sense of resilience and empowerment, further contributing to an environment within which positive change and growth may occur.

Maintaining Focus on Specific Problems and Coping Strategies:

Starting “small” and gradually eliciting more significant maladaptive responses &/or behaviors helps keep therapy focused and relevant; it also increases therapist understanding of the inner experience of the client with ADHD.

In addition, it is useful to help clients recognize how their symptoms influence their coping mechanisms (how they deal with disturbances in working memory and selective attention, for example) in order for them to develop and implement new ones (such as taking notes or asking for something to be repeated). This paves the way for clients to become more self-confident and empowered.

References

Neuroscience Education Institute (2009 October 24). Clinical update on ADHD: A one-day symposium. Presented at a meeting of the Neuroscience Education Institute. Seattle, WA.

Ramsey, J.R., Rostain, A.L. (2007). Psychosocial treatments for Attention-Deficit/Hyperactivity Disorder in adults: Current evidence and future directions. Professional Psychology: Research and Practice, 38, 338-346.

Rostain, A.L., Ramsay, J.R. (2006). A combined treatment approach for adults with ADHD: Results of an open study of 43 patients. Journal of Attention Disorders, 10, 150-159.

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