Different Treatment Plans for Adults with ADHD

            What happens to children with Attention-Deficit/Hyperactivity Disorder when they become adults? Do the symptoms vanish with adulthood? The reality of the situation is that “90% (Bierdman et al)of adults diagnosed with ADHD in childhood report continued low levels of overall functioning”(Wadsworth & Harper, pp. 102). The disadvantages of hyperactivity and impulsivity, which characterize children with ADHD, usually fade away as children become adults. The defining characteristics of ADHD in adults are under stimulation and inattentiveness, which can lead to various social, relational and occupational difficulties.  The ADHD of childhood and the ADHD of adulthood are two very different things with very different approaches to treatment.  This is an important distinction to make; one cannot apply a treatment model for ADHD children to ADHD adult.  This will not only be ineffective, but it could also adversely affect adult patients to not seek treatment and live with the difficulties of ADHD with shame and lack of medical treatment. The scope of this report will cover types of treatment measures for adults with ADHD, they are: psychotherapy/cognitive-behavioral skill training and preventative disclosure strategies. But before different types of treatment approaches and measures are to be considered, an understanding of the background and diagnosis of ADHD in adults is necessary.

            In the early nineteen hundreds some physicians thought the behaviors that we now recognize as ADHD disorder behaviors were a lack of morality and a resistance to accept the surrounding cultural expectations. Two decades later other physicians began to make the link between these behaviors and neurobiological damage or disorder, particularly in the cerebrum. This sparked more research that would eventually recognize the correlation between impulsivity and hyperactivity in children and “neurobiological disorder of the frontal lobe” (Quinn et al 1995). The sad truth is that the majority of parents with ADHD pass on those dysfunctional genes to their children. The neurobiological disorder manifests itself in abnormal behaviors that we all have seen in a friend or co-worker, but what is really happening inside the mind of someone with ADHD? “The hyperactive and inattentive behaviors in adults are thought to be the result of an under-responsive regulation of neurotransmitters or neurotransmitter functions in the prefrontal cortex” (Erk 2000). This is the neurobiological disorder that children and adults have within their neurological makeup, having this disorder hinders the patients from doing many things that we who have normative neurobiological makeups take for granted. “The clinical expression of the under-responsive behavioral inhibition system includes the inability to prioritize and implement four executive functions: (a) nonverbal working memory, (b) internalization of self-directed speech, (c) self-regulation of mood and arousal, and (d) reconstitution of the component parts of observed behaviors”(Barkely,1997).

Little to none research has been done on adults with ADHD; even though the diagnosis of ADHD is prevalent in our culture. The majority of studies and treatment plans have been for children, but no one has worked at solutions to the problems adults face with ADHD. “It is important to note, however, that those with behavioral disturbances (such as ADHD) face stigmatization, which may play a role in the social difficulties they experience (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000). Research has demonstrated that the general public endorses stigmatizing attitudes towards individuals with psychological disorders and that this stigmatization often results in negative outcomes such as rejection, social withdrawal, and exacerbation of psychiatric symptoms (Schumacher, Corrigan, & Delong, 2003).”  The options for treatment plans are few and the social and occupational difficulties can feel overwhelming. That’s what motivated a research team to look for ways that these adults can alleviate and cope with the stigmatizations of ADHD behaviors. A treatment plan was proposed, the main focus would be an attitude change in the patients. This is manifested by the proactive approach of “Preventative disclosure-an attempt to counteract social stigma by selectively using both concealment and disclosure of one’s condition” (Joachim & Acorn, 2000; Troster, 1997). The idea is that by disclosing one’s condition early on in a social interaction would hopefully prevent misattribution by peers or stigmatization by the public. What makes this study unique is that a preventative disclosure study has never been done for young adults with ADHD; the treatment has only been applied to those with other chronic illnesses. This study had 306 participants, around half were female, and the age range was from 18-26 with an average age of 22.5. The participants had to fill out a survey consisting of vignettes “The vignettes differed according to a two (ADHD symptom presentation: hyperactivity vs. inattentive) by two (preventative disclosure of disorder vs. nondisclosure) design.”(Jastrowski et al). The results of the study produced some very significant observations about this method. “There was a large effect of preventative disclosure in socially rejecting attitudes and a medium effect on beliefs that characters would benefit from treatment… First, the data indicate that individuals with ADHD who disclose their diagnosis may prevent negative social consequences, such as social rejection.”(Jastrowski et al). Of course this preventative treatment is not a cure, but it is an effective way of dealing with one aspect of the difficulties that adults with ADHD deal with. The researchers suggest more studies are needed to be conducted with a greater diversity so that these results may be more generalized.

In this section the psychotherapy/cognitive-behavioral skills treatment plan for adults with ADHD will be discussed.  A pilot study was conducted by Hesslinger et al 2002, in this research study researchers recognized that there were no Psychotherapeutic and behavioral skills studies being done or that have been done.  They decided to perform a study that analyzed how Adults who fit the DSM-IV criteria for ADHD disorder would respond to Psychotherapy involving cognitive-behavioral treatment. What they decided to use was the “DBT” or Dialectical Behavioral Therapy first developed by Linehan et al 1993. This treatment plan is usually used for those dealing with Borderline Personality Disorder; this treatment plan was chosen because often times those who have BDP exhibit similar psychopathologies with those who have ADHD. Such behaviors include “deficits in affect regulation, impulse control, substance abuse, low self-esteem, and disturbed interpersonal relationship are common in both conditions.”(Hesslinger et al 2002).  Before introducing the test subjects to the treatment and DBT program they first modified it by conducting a pre-treatment group of ADHD adults who went through the treatment. After going conducting sessions with the test subjects they modified the DBT so that it would be geared more to ADHD. The test consisted of eight participants, 5 male and 3 female, their age range was 19-44 with an average age of 31.9. Two of the participants were on medication at the time, Methylphenidate and anti-depressants, participants with ADHD participating in research studies with medication is common due to misdiagnoses, anti-depressants and or new stimulant drugs that are being newly developed. The treatment developed by Hesslinger et al were conducted in a group setting, the contents of the treatment included various skills: mindfulness was the first skill learned, the source of this skill was from the DBT program. “In DBT there are three “what” skills (observing, describing, participating) and three “how” skills (taking a nonjudgmental stance, focusing on one thing at a time, being effective)” (Linehan M et al). The second skill that the participants learned was “Chaos and Control”, essentially it is a perspective change for the patient, learning how to take control of their ADHD instead of letting it take control of them.  The third step was a whole process of analyzing behaviors that the patients wanted to change, this involved “detailed and precise description of the behavior, preceding events, predisposing constellations,” etc… (Hesslinger et al). The next step was more educational; participants were taught how ADHD can create emotional stability. This step had them using a journal to record their thoughts and education on emotional regulation.  The other steps of the treatment involved education with skill training, they were skills of impulse control, dealing with stress, substance dependency, how ADHD affects one’s personal relationships, and the some sessions involved family members and significant others in these sessions. The results of the treatment were extremely positive, on several skill inventories and a depression scale all the patients had scores that showed significant improvement. Not only were the numbers positive, but

“The treatment was generally regarded as helpful and, in particular, as very specific for the deficits that patients experienced. Patients felt better educated and felt they were better able to cope with ADHD. All patients stated that the setting as a group was most helpful. Psychoeducation, the therapists, and the exercises were mentioned as further helpful factors in a descending order. The rating of the different therapy modules mentioned above was very heterogeneous; however, none of the modules was assessed as unhelpful.”(Hesslinger et al 2002).

The success of this study is also evident by how many dropouts they had, none and many wanted to continue the therapy. This is an astounding lack of dropout rate considering the disadvantages of the subject group’s tendencies towards lack of persistence and instability. There were some drawbacks to the study; mainly the study’s low sample number creates a difficulty in trying to generalize the findings to the whole adult ADHD population. There are also limitations to this study as well; many behavioral treatment measures have been tested on children with no significant results. This means that the treatment cannot be universalized to children; this seems to be true because children lack the self motivation that the adults do. But the successes of this study cannot be overlooked, if anything this pilot study should be the harbinger for many more studies like it to come along and the treatment to be more widely used in ADHD adults.

            Even though not many studies have been done in the past on adult Attention-Deficit/Hyperactivity Disorder, the future looks hopeful due to the growing interest in researching this population. Many research teams are now taking a closer look at the problems and solutions of this disorder. Psychotherapy/Cognitive-behavioral skills training proved to have significant results as well did the Preventative disclosure approach. These and hopefully many more treatment options will be available to adults with ADHD.

References:

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Wadsworth, J.S. & Harper, D. C. (2007). Adults with Attention-Deficit/Hyperactivity Disorder: Assessment and Treatment Stratgies. Journal of Counseling & Development, 101, Vol. 85.

Quinn, D. Q. (1995). Neurobiology of attention deficit disorder. In K.G. Nadeau (Ed.), A comprehensive guide to attention deficit disorder in adults: Research, diagnosis, and treatment (pp. 18-31). New York: Brunnel Mazel.

Erk, R. R. (2000). Five frameworks for increasing understanding and effective treatment of attention-deficit/hyperactivity disorder: Predominately inattentive type. Journal of Counseling & Development, 78, 389-399.

Barkely, R. A. (1997). Behavioral inhibitions, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121, 65-94.

Linehan. M. (1993a). Cognitive-behavioral Treatment of Borderline Personality Disorder. The Guilford Press, New York.

Linehan. M. (1993b). Skills Training Manual for Treating Borderline Personality Disorder. The Guilford Press, New York.

Hesslinger B, Tebartz van Elst L, Nyberg E., D. P, Richter H, Berner M, Ebert D (2000). Psychotherapy of attention deficit hyperactivity disaster in adults: A pilot study using a structured skills training program. Eur Arch Psychiatry Clin Neurosci, 252, 177-184.

Hallowell, EM. & Ratey J. (1994). Driven to Distraction. Pantheon Books, New York.

Crisp, A.H., Gelder, M.G., Rix, S., Meltzer, H. I., & Rowlands, O. J. (2000). Stigmatisation of people with mental illnesses. British Journal of Psychiatry, 177, 4-7.

Schumacher, M., Corrigan, P. W., & Delong, T. (2003). Examining cues that signal mental illness stigma. Journal of Social and Clinical Psychology, 22, 467-476.

Joachim, G., & Acorn, S. (2000). Stigma of visible and invisible chronic conditions. Journal of Advanced Nursing, 32, 243-248.

Troster, H. (1997). Disclose or conceal? Strategies or information management in persons with epilepsy. Epilepsia, 38, 1227-1237.

Jastrowski, K. E., Berlin, K. S., Sato, Amy F., Davies, W. Hobart (2007). Disclosure of Attention-Deficit/Hyperactivity Disorder May Minimize Risk of Social Rejection. Psychiatry, 70, 274-282.