December 1st, 2016

Clinicians help adults with ADHD

Psychologist David Nowell, Ph.D., said that adult ADHD is manageable with organization and assistance from the patient’s inner circle.

Attention deficit disorder or attention deficit hyperactive disorder is most often associated with young children and adolescents. But symptoms that manifest in childhood sometimes persist into adulthood and, in other cases, signs first initiate well past the early years.

The Anxiety and Depression Society of America reports that approximately 60 percent of children with ADHD in the United States carry the diagnosis into adulthood; that amounts to four percent or eight million adults.

Fewer than 20 percent of adults with ADHD have been diagnosed or treated, according to the Society.

David D. Nowell, Ph.D., private practitioner with offices in Worcester, Northboro and Brookline, Massachusetts, pointed out that clinicians should carefully evaluate adult patients who present with what might seem like symptoms of ADD/ADHD.

“You have to rule out five to 10 common things, such as Lyme disease, sleep apnea, fibromyalgia, head injury, depression or substance abuse,” he said.

Some adults over the age of 50 most likely were not properly assessed when they were children, although some literature suggests that ADHD can appear later in life, he added.

“For example, menopause is associated with increased cognitive burden. There could also be some subtler symptoms, including life stress, hormonal changes, chemotherapy or a new diagnosis.”

Adult ADHD is manageable with a bit of organization and assistance from partners, life coaches or advisors, Nowell noted.

“If someone with adult ADHD is married to someone with good executive functioning, they can act as a coach. Without structure, adults may suffer more. It’s most important to develop expectations related to vocational activities and education,” he said. “There is a discrepancy, a gap between ability and performance.”

While stimulant medication tops the list of evidence-based treatment, Nowell also suggests developing and nurturing organizational skills.

He recommends that patients carefully examine the tasks at which they excel and that engage them and delegate those that don’t. “What niche skill can you concentrate on and outsource other things? A coach can help create a targeted strategy for specific functioning and problems that appear in the moment,” he said.

Other non-medication options, which Nowell considers “crucial,” are good sleep hygiene and protein intake. “You should eat half a gram of protein for every pound of body weight. Protein supports cognition for hours, while carbohydrates support cognition for minutes,” he said.

Eliminating preservatives from the diet and getting adequate physical exercise are also on Nowell’s recommendation list.

Selene MacKinnon, Psy.D., a psychologist at RICBT in East Providence, R.I., adds that the first line of treatment for adults who present with ADHD should be a good evaluation and diagnosis by a trained professional.

While a stimulant or non-stimulant medication might be appropriate, she pointed out that medication addresses only approximately half of the symptoms. “Additional support is needed. Cognitive behavioral skills and social skills training should be taught in a structured manner to help manage distractions,” she said.

Moreover, co-existing mental health conditions are fairly common in adults with ADHD and require general psychotherapy as well as skills training.

“Up to 75 percent of adults with ADHD have at least one other psychiatric diagnosis, but what that diagnosis is ranges a lot,” she said. “ADHD is a core neuropsychiatric impairment and leads to underachievement and failure, which leads to negative thoughts. The person then approaches tasks with no confidence and this becomes mood problems as adults.”

While there is no direct correlation between ADHD and physical conditions, there could be some consequences, MacKinnon noted.

Significant forgetfulness could cause the person to improperly manage the physical problem that might include failure to complete medical paperwork, follow instructions on wound and postoperative care and stay organized with medication regimen, she said.

For the most part, males and females with untreated ADHD have similar consequences, although the latter runs the risk for additional problems.

“[Females] have an increased risk of low self-esteem, depression, teen pregnancy, anxiety and smoking in middle and high school,” MacKinnon said.

Women also face a greater chance of divorce, financial difficulties, underachievement, substance abuse and/or eating disorders and demonstrate learned helplessness, she noted. Furthermore, women who have ADHD are more likely to have children with ADHD.

To help patients improve cognitive and behavioral skills, MacKinnon offers a 12-week course that addresses chronic procrastination, among other issues. “[Adults] have several unfinished tasks and are under achievers. They may shift careers and demonstrate impulsiveness and physical and cognitive restlessness,” she said. “They have poor decision making skills and driving records. Adults with ADHD have trouble realizing their full potential.”

MacKinnon’s ongoing advanced training program helps to enhance cognitive and behavioral skills with the added feature of a support group. “This group is for individuals who’ve already had skills training and wants peer support,” she said. “Skills previously learned are strengthened and patients learn new ones.”

In spite of troublesome behaviors, adults with ADHD have many positive qualities, MacKinnon said. She reported that they have “energy, creativity, are quick thinking, intuitive and spontaneous.”

She said, “ADHD in adults has only recently been recognized as a disorder. We still have a lot to learn.”

David Margolis, Ph.D., private practitioner in Portland, Maine, treats a fair number of patients who have self-diagnosed after taking online tests. “But what looks like ADHD might be something very different down the road,” he said. “The top categories include mood dysregulation, anxiety disorder or a depressive disorder.”

But even when an ADD/ADHD diagnosis is confirmed, patients needn’t be unduly concerned, according to Margolis, who is a proponent of planning. “We live in an instant solution environment. Folks with an ADHD diagnosis have real difficulty with time estimation – the time it takes to do a task – and time management,” he said.

Margolis helps his patients manage their ADHD by suggesting tactics to reduce chaos and embarrassment.

“It all feeds into self-regard, self-worth,” he said. “By the time people come to me they have developed with failure. They may have had multiple marriages. They see themselves often as reasonably bright but that doesn’t translate to performance. It affects self-perception and mood, which are tied together.”

Rather than eliminate the problem, Margolis helps patients find “work-arounds” that help to manage the condition. He pointed out that people with ADHD are “highly distractible” and only think about what’s in their visual field.

“It’s not just time sequencing, but figuring out degrees of importance. You can’t do it all,” he said. “You need to plan how to use your time. Many tasks are divisible.” Acceptance is an important part of dealing with the condition, he emphasized.

By Phyllis Hanlon

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