Psychosocial treatments for Adult ADHD – Final Coursera ADHD Thoughts

A camping trip with my youngest child delayed this last posting on the final lecture from the Coursera class on ADHD. It was buggy, cold, and rained most of the trip. Watching him jumping around in the campsite, hopping from rock to rock in the cold rain, brought home to me one of the important criteria for a true ADHD diagnosis. No matter how active a person is or how often they switch their focus, they cannot be clinically diagnosed with ADHD unless it causes impairment. My son’s natural inclination to be constantly in motion at the campsite may be an evolutionarily desirable trait. Perhaps high-energy children were less likely to be overcome by hypothermia and were more likely to reach adulthood and have children of their own.

Yet ADHD traits are not at all helpful in modern classrooms and offices where children and adults are expected to sit still and focus their brain power on tedious items. That does not mean that ADHD traits are not adaptive for other situations and environments. The trick for adults with ADHD tendencies is to find occupations and environments that work with their natural high energy and high distractibility as much as possible. Then structure their lives and surroundings with external scaffolding to compensate for their relative lack of internal executive organization and function.

As a person with ADHD moves from childhood through adolescence to adulthood the manifestations of their ADHD evolves. A child with ADHD is likely to show high physical activity, aggressiveness, low frustration tolerance, and impulsiveness. An adolescent with ADHD is more likely to sit still but will be easily distracted and inattentive. An adult with ADHD will frequently shift activities, be impatient, restless, and easily bored. Incidentally, this may also be true of a highly gifted individual who is in a unfulfilling occupation. What makes the ADHD adult stand out is that the impairment is usually across multiple domains. A lifetime of  ADHD, especially ineffectively treated ADHD, can highly impair an individual. From finances to occupations, relationships to physical and mental health, ADHD takes its toil. One of the most insipid effects is the demoralization that can occur due to a negative belief system. Adults with ADHD have typically spent years watching themselves fail to meet seeming simple challenges. They may not have good coping skills and may have developed a paralyzing hopelessness that feeds into their self-image.

Medical treatments for ADHD are a critical part of the treatment for adult ADHD, yet pills alone cannot teach new coping skills or help individuals recover from a lifetime of negative self talk. Psychosocial interventions that have shown promise include helping individuals, either individually or in groups, with psychoeducation, problem management, decision-making, procrastination, organization, time and effort management, cognitive modification, and behavior modification. Cognitive Behavioral Therapy (CBT) is very effective for adults with ADHD especially when combined with specific treatment goals and organizational strategies. Therapists can help adults with ADHD externalize their executive functions as much as possible.

Adults with ADHD need to put in more effort than more cerebrally typical people to keep themselves organized and on task. The good news is that many of the behavior interventions that help tame ADHD tendencies are generically healthy for everyone. They include creating regular routines for waking times and bedtime to ensure a full night of sleep. Daily exercise to increase available dopamine for clearer thinking and better focusing. Eating regular nutritious meals with a low glycemic index to prevent hypoglycemia which increases ADHD symptoms.

Environments should have an organizational structure with specific places for items that are easily misplaced such as keys and papers. Electronic reminders, especially ones easily programmable on smart phones, can help individuals stay on task while not getting so lost in an activity that they accidentally miss upcoming events and deadlines. Visible timepieces, concrete plans with start and end times, and regular reviews of what is working and what needs a better strategy all help the adult with ADHD. It is important for the adult to forgive themselves and to be realistic. Recognize what does work vs. what should work. Find the right tools to address outstanding problems and automate and/or outsource problematic tasks whenever possible. Recognize that certain feelings and situations may lead to detrimental impulsivity and prepare plans and coping strategies to avoid or mitigate this type of predictable trouble.

Beyond drugs and psychosocial therapy there are a few other ADHD treatments worth mentioning. Although not enough data is available to determine how to maximize the effectiveness of these treatments, neurofeedback, computerized cognitive training, and targeted working memory training are all showing some promise in treating ADHD.

The bottom line is that, especially given the more liberal definition of ADHD in the DSM-V, if you feel like you are impaired by ADHD, help is available. Although drugs might be part of the solution that works for you, do not neglect your environment. The more you can do to structure your world and life in a way that works with your brain’s natural tendencies, the more effective you will be.

Managing Childhood ADHD Without Drugs: Coursera ADHD Class Week 11

The last couple weeks of the Coursera class on ADHD focused on how to live with and manage ADHD symptoms without drugs. “Pills don’t teach skills” and whether parents of children with ADHD or adults with ADHD embrace the idea of medical therapy, drugs are not the only treatment approach for helping someone with ADHD thrive.

Students with ADHD need support both at home and within their school environment. In fact, the US Department of Education has put together a fairly comprehensive brochure on how to teach children with ADHD. After giving teachers some guidance on how to identify children with ADHD, it has three separate sections on how to help a child with ADHD be successful in the classroom. Although rumors abound about teachers that, subtly or not so subtly,  have told parents to put their kids on ADHD drugs, that isn’t one of the teaching strategies. Instead the pamphlet focuses on instruction techniques, effective behavioral interventions, and classroom accommodations. It suggests a student with ADHD should sit closer to the teacher and farther from distracting kids. Wow, who would have thought? I know some elementary school teachers are resistant to “special” seating “privileges” for students with ADHD, perhaps referencing this official brochure will help parents get the seemingly minor accommodations their children need. Multiple times the brochure makes the point that children without ADHD also thrive in classrooms that are structured to help children with ADHD. Basically, these are strategies that can help any teacher be more effective regardless of the makeup of their classroom in any given year.

At home, one of the most effective treatments for children with ADHD is teaching their parents better behavior management strategies. By acknowledging that their child has below age-level-norm organizational, self-control,  and coping skills, parents can structure the home environment with scaffolding supports to help the child succeed despite their ADHD symptoms. There are several different training programs for parents. Most have similar elements: stay calm and don’t get emotional, analyze what is working and what isn’t, rely on planning and praise to gain compliance, go to the child to give instructions — use eye contact and touch to get child’s attention before giving instructions, break large tasks into smaller ones, use labels, file cards, and other visual cues and organizers to make tasks less daunting, reduce time delays for consequences (positive and negative), and use warnings, “when-then”, token economies and time outs to guide behavior. Work with the child to create better habits and more effective behaviors. If the child is encouraged to help evaluate the results of the program, it can increase their commitment and desire to change.

One comprehensive parent behavioral training program covered in some detail was one developed by Russell Barkley. Dr. Barkley has written extensively about executive function, defiant children, and how to take charge of ADHD. Putting the effort into learning how to be a better parent for a child with ADHD is very worthwhile. Studies show that not only do children do better with more effective parenting, parental stress is also decreased and satisfaction is increased under these programs.

Adults with ADHD face slightly different challenges than kids with ADHD. Some of these challenges stem from the bad habits and/or negative thought patterns that can develop over a lifetime of living with ADHD. My next post, and the last in this series, will cover psychosocial treatments for adults with ADHD.