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.