Psychotherapy Goals, Structure, and Challenges

Despite significant cognitive improvement from stimulant medication, often the coping skills of adults with ADHD remain suboptimal. Psychotherapy focuses on improving coping skills to effectively address cognitive and emotional challenges. Psychotherapists also help the client process the emotional fallout from years of untreated ADHD and perceived failures. Cognitive-behavioral therapy (CBT) for ADHD focuses on psychoeducation, acquiring healthy habits and coping skills, and examining maladaptive cognitions that naturally develop from living with ADHD. ADHD behaviors that may interfere with effective treatment are addressed, including lateness, poor time awareness, missed appointments, tangentiality, motivation problems, homework problems, medication nonadherence, and social problems at work and home.

Recognizing Strengths

Strengths may come from ADHD itself or from the experience of living with ADHD. This topic has been neglected by researchers, as most research focuses on the disadvantages of ADHD; therefore, much of this chapter is speculative, based on clinical observation and anecdote. Possible advantages people with ADHD may have include having a high energy level, being extremely passionate about and dedicated to things that interest them, having the ability to power through a large task, being creative and innovative, being valuable team members, having entrepreneurial zeal, having high levels of adaptability and resilience, being nonjudgmental, and being good at using their strengths and resources.

Adult ADHD Symptoms

Understanding the symptoms of adult ADHD is an essential starting place. Diagnostic and Statistical Manual of Mental Disorders symptoms of ADHD are reviewed, including inattention/distractibility, impulsiveness, and hyperactivity, as well as other adult ADHD symptoms that have been well documented in multiple research studies. Suggested interview questions for each symptom are presented. Additional adult ADHD symptoms include executive functioning deficits, emotional dysregulation, atypical reward sensitivity, and time perception differences. Sluggish cognitive tempo is also defined and a case example given. Last, progress towards a new definition of ADHD is presented, and the practicalities of diagnosing ADHD using the International Classification of Diseases, 10th Revision, are discussed.

Comorbid Conditions, Emotional Distress, and Dysfunctional Cognitions

At least 70% of adults with ADHD have at least one comorbid disorder. Substance abuse is common. Why are people with ADHD more likely to have anxiety and depression? Perhaps there is shared genetic vulnerability. Perhaps certain environmental risk factors increase both the risk of ADHD and anxiety or depression. Plus, the stresses of living with ADHD make people feel anxious and depressed. Adults with ADHD feel more stress and have more stressors. Adults with ADHD may be especially prone to worry, rumination, and negative automatic thoughts. ADHD is not caused by maladaptive cognitions, but adults with ADHD have more negative automatic thoughts, even when they are not depressed. Maladaptive positive cognitions can be problematic as well and often maintain dysfunctional behavior in adults with ADHD.

Psychoeducation about Cognitive Differences

Psychoeducation is probably the most powerful and effective intervention for ADHD, and experts universally agree that psychoeducation is essential for effective treatment. Clients learn to understand the differences in how their brains function and how this has contributed to their difficulties. Psychoeducation helps clients stop telling themselves that they “should” be able to use their brains the same way everyone else does. These insights empower the client to learn, develop, and deploy effective individualized coping strategies. Some of the challenges of ADHD are also examined in this chapter, including attention problems, working memory deficits, distractibility, hyperactivity, time estimation problems, emotional dysregulation, and others.

Review of Other Treatments for ADHD

Many treatments have been suggested for ADHD over the years. The effectiveness of some of the most commonly considered treatments, other than psychotherapy and medication, are discussed in this chapter. These include omega-3 supplementation, other diets or supplements, cognitive rehabilitation, neurofeedback, mindfulness training, and coaching. Omega-3 supplementation for children is the only one that has proven benefits. More research is needed on the others. Ineffective and unproven treatments are also mentioned, including acupuncture, chiropractic adjustment, interactive metronome training, repetitive transcranial magnetic stimulation, sensory integration training, vision therapy, massage, mirror feedback, vestibular/cerebellar exercises and homeopathy.

Medications

An understanding of medication treatment for ADHD is helpful to educate clients about the benefits and to facilitate collaboration with psychiatrists and other prescribers. Psychotherapy is helpful for organizational skills but leaves the client with continued cognitive difficulties. Stimulant medications effectively address these cognitive problems and are currently considered the most scientifically validated treatment of ADHD. Stimulant medications are well tolerated by clients and have been prescribed safely for decades. Only one nonstimulant medication, atomoxetine (brand name Strattera), has been approved by the FDA for adults with ADHD. Individuals with ADHD may be reluctant to take medication. In these cases, psychotherapists are directed to inquire about the client’s concerns about medication. Some people with ADHD function well without medication. This is an understudied area of research, so little is known.

Assessing Family History, Childhood, and Adult Development

Symptoms of ADHD emerge when the environmental demands exceed the resources that the person can bring to bear. Internal and external resources change with personal circumstances, developmental level, age, and maturity. ADHD is among the most heritable mental illnesses. Prenatal and childhood risk factors impact the likelihood of ADHD developing. Challenges for children, adolescents, college-age adults, and older adults with ADHD are presented, with a special focus on emerging adults. Whether childhood ADHD remits in adulthood is discussed, as well as whether ADHD can emerge in adulthood. Clinical interview questions to diagnose whether childhood ADHD went undiagnosed are presented, including those that explore ADHD symptoms; development, emotional, and behavioral problems; and educational and learning problems.

Meet Clara and Troy, Two Adults with ADHD

Adult ADHD continues to be underrecognized by mental health clinicians, even when clients with ADHD are already in treatment for other mental illnesses. Research finds that one out of every 5 to 10 people in therapy have ADHD. The cases of Clara and Troy are used to demonstrate key points about the experiences and difficulties of adult ADHD. Dialogue from their first psychotherapy sessions is given to show presenting problems. In addition, myths about ADHD are addressed along with the facts that disprove them. Core characteristics of adult ADHD are described, and a brief review is provided of common functional impairments and the emotional impact of adult ADHD.

Skills Training

Developing effective organizing and planning skills is an essential element of effective treatment of ADHD because these skills improve functioning. People without ADHD learn organization and planning skills naturally as they go through life. Because of cognitive differences, these skills do not come naturally to adults with ADHD, so they may have to be learned. Almost all adults with ADHD have some deficits in organizational skills. Clients with ADHD do not typically think through their problems systematically, prioritize, and make plans. Instead, they tend to react impulsively or avoid. The information in this chapter draws heavily on two manualized treatments to help people with ADHD manage their symptoms and improve their skills in managing everyday life.