Adult ADHD: Never too late to treat

Undiagnosed adult ADHD is understood to be a chronic condition that can lead to many problems of living and emotional difficulties. Among the problems my clients struggle with are academic failure, abandoned college and university programs, employment instability, and mental health issues that develop as secondary issues to untreated ADHD–including addiction, anxiety, and depression. On a day-to-day level, untreated ADHD leads to significant chaos in the home life–disorganization, inefficiency, financial problems (due to lack of planning and impulse spending), and poor emotional regulation are some of the issues that drive my clients into treatment. The prevailing feeling virtually every client reports is that he or she is expending a disproportionate amount of energy and effort just to barely keep their lives from falling apart, let alone be able to enjoy quality of life. Relationships and family life are hit especially hard. In marital therapy, one client’s wife tearfully expressed how tired she was of living in “damage control mode” because her husband was so unreliable and disorganized.

Many of my adult clients are coming to understand for the first time that they have ADHD. This is not surprising as the diagnosis did not exist when they were children, and so they spent their developing years struggling and underachieving without understanding why. As adults, they are left with a chronic deficit of self-worth on top of the ongoing difficulties created by untreated ADHD.

There is nevertheless significant hope for the adult with ADHD. Below I list the basic steps to remediate ADHD and get life back in order.

1. Obtain a formal ADHD assessment

This should be done with a Registered Psychologist who is familiar with ADHD diagnostic guidelines for adults and has access to research-based standardized assessment measures. It is important that the psychologist you choose understands the nuances of diagnosing adult ADHD versus childhood ADHD, because most ADHD screening instruments are based on DSM-IV-TR diagnostic thresholds which were developed on children. (The DSM-IV-TR is the definitive manual of diagnoses published by the American Psychiatric Association.)

The adult who suspects that he or she has ADHD should also be careful of “quick and dirty” diagnostic screens that are sometimes administered by their family doctors. It is disturbingly common to hear of diagnoses being rendered based on quick questionnaires (sometimes the very same self-diagnostic questionnaires widely available online) that do not capture the full picture of adult ADHD. A number of GPs I have advised are surprised that this is an invalid way of diagnosing ADHD. Best practices suggest that multiple components are needed in ADHD evaluation, including taking a careful developmental history, obtaining collateral information from different sources (including, ideally, a primary childhood caregiver), and conducting careful differential diagnosis. Differential diagnosis, the process of identifying whether the symptoms are attributed to ADHD or some other condition, is crucial because other conditions (such as anxiety, depression, or a learning disability) can resemble ADHD.

After the only provincially-funded adult ADHD clinic closed down in 2007 (with an ever-expanding waitlist reaching up to 14 months), diagnosing adult ADHD now falls to psychiatrists, GPs, and psychologists. Since these clinicians may or may not be knowledgeable about assessing adult ADHD, it is important to choose a clinician carefully. Typically, a psychologist who also conducts psychoeducational testing will have the background and tools for evaluating adult ADHD.

2. Work with a psychologist to learn ADHD self-management skills

Many clients find a course of psychotherapy to be extremely beneficial for better understanding ADHD and developing a set of self-management tools based on cognitive-behavioural therapy (CBT). Given that ADHD is a chronic condition, learning ways to self-monitor and manage the condition is essential to life success. Self-management requires a combination of internal and external resources. An internal resource is one that is self-generated–e.g., insight, meta-cognition (thinking about one’s thinking), time management, and self-motivation. External resources are “props” that help to keep life organized–a planner, automatic reminders for appointments, logical organization systems, etc. Noted ADHD expert Dr. Russell Barkley likens external resources to prosthetics that help the ADHD mind to do its job.

Psychotherapy can help adults with ADHD to develop better self-monitoring and heuristic (trial-and-error) learning strategies to work out and keep refining a personal set of self-management strategies. Some of these strategies can be quite idiosyncratic. For example, one client, a university student, learned that she needed to allow herself more time to study for tests. By experimenting with different strategies (the heuristic process), she learned that doing a quick second review just before her test allowed her to exploit her working memory and improve her recall on tests.

Finally, given that ADHD is associated with poorer emotional self-regulation, psychotherapy can assist clients in improving their emotional and stress management skills, as well as address the secondary psychological issues (e.g. anxiety and depression) that may have arisen because of untreated ADHD.

3. Seek a medication evaluation by your family doctor

The most common psychotropic medications for managing ADHD are psychostimulants–examples include Adderall, Concerta, and Focalin. Non-stimulants, e.g. Straterra or Wellbutrin, may be considered if stimulants are not well tolerated. I encourage clients to speak to their physicians about the potential for a course of medication to assist in symptom management. Physicians will often use my report as the basis of their diagnosis and treatment plan. Medication can have its place in a broad-based, holistic ADHD management strategy (see below). I encourage clients to use medication in the spirit of Dr. Russ Barkley’s metaphor of the “prosthetic” allowing the ADHD mind to do its job effectively. For many adult clients, the increase in focus that medication can bring is very empowering and predicts even greater success in psychotherapy (otherwise even remembering to come for the appointment, let alone remembering to implement recommendations, can be a struggle). However, medication is not always necessary if psychotherapeutic and other strategies can be employed successfully. Among my clients, if medication is essential, I work with their physicians to develop a treatment plan that includes ongoing symptom monitoring.

4. Address ADHD holistically

Clients should employ a toolkit approach, bringing to bear whatever resources are helpful in symptom management, including medication (if warranted), psychological and behavioural coping skills, lifestyle modification (including nutrition and exercise), and complementary alternatives such as yoga and meditation. Every client, if he or she is motivated and willing to experiment, eventually discovers a repertoire of strategies that is successful, allowing them to do more than they once thought possible.

 

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Coping well with ADHD: Tips for parents

“I’ve had it!” Every parent has experienced reaching the limit of patience and losing their cool with their ADHD child. Perhaps they may even cross the line and say words they end up regretting. The regret registers as quickly as the hurt look that comes over their child’s face, or the terrified look that acknowledges the power of a parent to carry out spirit-crushing threats. Many parents are familiar with the ensuing self-blame over damaging words that, once said, can never be taken back.

As a psychologist helping both kids with ADHD and their parents, I am familiar with the frustrations and feelings of inadequacy that loving parents can experience in their daily struggles of parenting an ADHD child. Because parents who have reached their limit may do and say detrimental things, I have summarized five coping strategies to help parents to keep their cool and love their kids through the tough moments:

1. Accurately attribute your child’s behaviour to ADHD, not a personal failing

A forgetful child is called irresponsible. A child with difficulty focusing and completing homework is called lazy. Another child who struggles to listen when spoken to directly is called rude or disrespectful. These words when spoken to a child convey personal failings that can damage their self-esteem and leave a lingering legacy of inadequacy and self-doubt. Remember that ADHD presents in ways easily mistaken for a moral or personal failing. Proper reattribution of the behaviour to ADHD can therefore help to reduce anger at the child and increase the capacity to parent lovingly through tough moments. Reattribution can take the form of consciously changing one’s self-talk from, “Johnny is so dumb for not being able to follow my instructions,” to “This is Johnny’s ADHD expressing itself.” Reattribution can also entail replacing charged or negative terms with more neutral ones, such as saying “inattentive” instead of “dumb.”

2. Focus on primary issues, not secondary ones

By the time parents come to me for help, there is often the sense that they are in crisis mode because the unmanaged ADHD has gotten so out of hand. Often I find that parents are overwhelmed because they are failing to distinguish between primary (or underlying) issues and secondary (or symptomatic) issues, and they are devoting scarce parenting energies to dealing with secondary behaviours that are driven by a more fundamental, underlying issue. Recently, one mother sought help to deal with a laundry list of problems with her son, “Tom.” Tom was oppositional, anxious, disorganized, failing in school, had low self-esteem, and there was significant tension in the family around Tom’s issues. After a couple of sessions with Tom, I found that most of his problems were driven by academic concerns – he was anxious and rebelled against studying because he lacked adequate organizational and study skills. Recognizing this helped Tom’s parents to focus on helping Tom improve his academic skills, pick their battles more wisely (e.g., they are no longer hell-bent on winning every argument), and feel less overwhelmed.

3. Forgive quickly

Let’s face it: Out kids can make us really mad sometimes. This is when the power of forgiveness can make a difference in how we cope. But what is forgiveness? It is easy to talk about forgiving but how do we actually do it? Forgiveness isn’t an attitude or a feeling. In a pragmatic sense, forgiveness is an act of giving up the right to stay angry at someone, with the understanding that you have every right to be angry and punish the wrong to obtain a “just” outcome. There is an implicit “justice seeking” mindset among parents who punish their children abusively – they carry out harmful punitive actions against their kids as “payback.” When parents forgive, i.e., give up their right to be angry and exact that payback, they will discipline with firmness and love but not punitiveness. A massive body of empirical and clinical evidence also indicates that they will feel calmer and cope better with their emotional stress.

4. Practice mindfulness

Mindfulness is a mental and emotional posture of neutrality and detachment. A central component of mindfulness is non-judgment. Mindfulness can reduce stress by helping parents to change their evaluation of stressors from “bad” to neutral. We naturally judge any negative situation as “bad” because it is unwanted. However, many of the stressors attendant to parenting a distracted and/or impulsive child are not bad in a moral evaluative sense. Stealing, hurting people and other moral transgressions are bad, but that same value judgment cannot be applied to your child’s ADHD traits. Moreover, stress itself is not bad – it is only stress (admittedly not good, but not bad either). The more we can see a trait or feeling as neither good nor bad but just is, the calmer we will be because we increase our acceptance of the experience and are more willing to work with it, rather than trying to get rid of the experience (after all, you would be more willing to have a neutral thing than a bad thing in your life). Take up yoga or meditation – these practices help to reduce stress by facilitating mindfulness.

5. Ask for support from your spouse or partner

In my clinical experience, the burden of dealing with the behavioural difficulties of kids with ADHD seems to fall on mothers. Typically, it is the mother who initiates the call, brings the child to my office, attends parenting sessions, reports ongoing issues and interacts with the feedback that I share. Many mothers that I work with report feeling stressed due to the lack of involvement of their husbands or partners. The burden of parenting behaviourally difficult kids needs to be shared. It is absolutely fair to ask for the support of your spouse or partner and convey an expectation of increased involvement. It is not hard to see that having added support will decrease your stress level in a number of ways, but sometimes asking for help is the difficult part as this can trigger conflict and bring up deeper marital issues. This is when a trained therapist can assist by helping couples to dialogue and agree on more reasonable parenting expectations. Asking for needed support and being able to count on that support is an important part of containing stress and preventing that scarce commodity of you from becoming depleted.

 

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