He is motivated, resilient, optimistic, and has a good support system. However, his negative automatic thoughts about his ability to succeed in school and to handle increasing time demands suggest deeper beliefs of inadequacy and failure.
Mr. B struggled academically. Without guidance about how to change his approach to difficult situations, he has repeated old thinking and behavior patterns. Believing he will embarrass himself and fail to learn required material, Mr. B procrastinates and avoids doing assignments. In class, his feelings of inadequacy make him self-conscious, which causes him to lose focus and have trouble concentrating.
See the world through the patient’s eyes
Understanding your patient. Before you start treatment, we recommend that you conceptualize how ADHD has influenced your patient’s life, including:
- developmental experiences
- family-of-origin issues, such as conflicts with parents stemming from ADHD symptoms or reciprocal interactions with an ADHD parent
- world view (“schemata”)
- patterns of coping with (or avoiding) stress
- attitudes toward self and important others
- readiness to change.
Developing a working case conceptualization is a dynamic, collaborative process. You talk with patients, and encourage them to reflect on how ADHD affects their view of themselves and their important relationships. The conceptualization takes shape as you:
- observe patients’ behaviors
- elicit how they think and feel
- assess with them the relevance and accuracies of their belief systems and response patterns.
Seeing the world “through their eyes” prepares you to help them accept the diagnosis and learn to manage ADHD symptoms. Then, by providing a blueprint to manage what patients may see as uncontrollable responses, you can help them take charge of their automatic reactions.
Psychoeducation. To set the stage for treatment, encourage patients to learn about ADHD by reading articles and books and consulting Web sites for adults with ADHD (see Related resources). Psychoeducation helps patients:
- review possible treatment approaches, including organizational (environmental) management, medication, and psychotherapy (individual or group)
- become informed participants in setting treatment goals.
Explain the relative contribution of each treatment component. For example, medications can reduce distractibility and improve attention, organizational strategies can reduce disorganization and improve time management, and structured psychotherapy can help the patient develop more effective coping skills.
Case continued: Planning combined treatment
You discuss diagnosis and treatment options with Mr. B, and he agrees to start the methylphenidate compound Concerta, initially at 18 mg/d, and weekly CBT sessions. You recommended a stimulant based on efficacy studies and your clinical experience in treating adults with ADHD. Mr. B wants a medication that will help him focus while working or studying, and he says Concerta has improved his son’s ADHD symptoms.
You instruct Mr. B to increase the dosage by 18 mg each week until he reaches 72 mg/d. You also tell him to keep a medication response log and to note any positive changes and side effects.
If an adult with ADHD expresses preference for a particular medication, we usually prescribe that one first. Most patients to whom we offer both medication and psychotherapy agree to this “top-down” and “bottom-up” approach. “Top down” means giving patients new ways of thinking to help them understand and modify their responses. “Bottom up” refers to the medication reducing their impulsivity, distractibility, and inattentiveness.
CBT for adult ADHD
Medications can ameliorate key symptoms of adult ADHD, but adjunctive interventions are needed to improve functioning and quality of life. Evidence supporting psychosocial treatment for adults with ADHD is limited, but CBT has been studied the most.1,9-13 Safren et al13 found a four-fold greater therapeutic response when patients received adjunctive CBT for residual ADHD symptoms, compared with patients who received medication alone.
We usually provide CBT weekly for 12 weeks and then taper to 8 additional sessions over 3 months (total 20 sessions). We may extend CBT with additional sessions to address complicated issues. CBT helps adults with ADHD to:
- identify dysfunctional thinking, feeling, and behaving patterns
- recognize contexts in which patterns arise
- systematically change these patterns.
CBT can reduce ADHD-associated anxiety and depression and improve coping skills and sense of well-being.1,9,11 Its flexibility allows you to address family issues with patients’ partners, children and other relatives to improve communication, reduce conflict, and develop healthier interactions.
We focus CBT sessions on finding alternate coping strategies. We might try role playing, rehearsing, creating “thought experiments,” and anticipating and preparing to modify typical patterns of avoidance. These approaches have been described elsewhere.10,11,14
We adopt an active stance during therapy to keep ADHD patients’ distractibility from disrupting our conversation. For example, we set the therapeutic agenda, provide feedback about patients’ behaviors, and encourage them to clarify rewards and consequences of using (or avoiding) problem-solving strategies.