Monday, October 31, 2011

Beyond Medications

Today’s guest blog is by J. Russell Ramsay, PhD.

If adults with ADHD could only have one treatment for their symptoms, research indicates that pharmacotherapy, particularly the use of stimulant medications, is the single most effective option for reducing the core symptoms of ADHD. However, medications alone may represent insufficient treatment for the many difficulties experienced by adults with ADHD, such as disorganization, procrastination, poor time management, mood and anxiety issues, and low self-esteem, to name a few.

During CHADD’s Annual International Conference on ADHD, my session on adjunctive treatments for adult ADHD will be held on Thursday, November 10. The session will cover the current status of various non-medication treatments for adult ADHD that are often used in combination with medications in order to help individuals achieve improved overall well-being and functioning in addition to symptom relief. Here is a brief overview of those treatments.

Psychosocial treatments. Many standard psychotherapy approaches have been modified in order to more effectively address the typical coping difficulties faced by adults with ADHD. In general, cognitive-behavioral therapy (CBT) approaches for adult ADHD, which focus on modifying self-defeating thought and behavioral patterns, have been found to be a useful adjunct to medications in several published studies, including recent randomized controlled designs comparing CBT with other active treatments. Sessions focus on the development and consistent implementation of coping skills in daily life. Psychosocial treatment, namely CBT for adult ADHD, stands out as the adjunctive treatment with the strongest research support.

Coaching. Although not the same as CBT, ADHD coaching shares the goal of helping adults with ADHD to employ more effective coping strategies to fulfill their personal goals. ADHD coaches target specific coping difficulties, such as disorganization and poor time management, and help clients develop and follow through on action plans. While the benefit of coaching support makes logical sense and it is an increasingly available option, to date there has been only one published study of its effectiveness for adults with ADHD adults.

Academic support and accommodations. Similar to ADHD coaching, while academic accommodations targeting specific areas of impairment make logical sense, such as extended time to complete an exam, these adjustments do not have research support. There are many informal steps that students can take to manage the effects of ADHD on their academic performance. However, there are preliminary studies of learning support and coaching approaches for college students with ADHD that have yielded positive results, making it a promising option.

Workplace support and accommodations. Workers with ADHD whose impairments fulfill the legal definition for a disability may be entitled to reasonable workplace accommodations, though most adults with ADHD do not pursue official accommodations. As with students, there are many informal adjustments in the work setting, assistive technologies, and other coping tools that may be helpful for adults with ADHD. As with academic accommodations, the effectiveness of these coping efforts has not been systematically studied.

Relationship treatment. Research on the effects of ADHD throughout the lifespan has increasingly identified its negative impact on family and social life for both children and adults with ADHD. The parents and caregivers usually participate in treatment programs for their children with ADHD, though they are rarely screened for ADHD despite high heritability rates. In fact, parental ADHD (even in sub-clinical form) is likely a common reason for dropout in family treatment programs for child ADHD and/or oppositional behavior.

Similarly, there may be unique difficulties faced in marriages and committed relationships in which one or both partners has ADHD. No studies have yet been published on either marital or family therapy involving adults with ADHD.

Neurofeedback and working memory training. Proponents of neurofeedback training cite numerous studies of its effectiveness, though there have been few studies using samples of adults with ADHD. Critics of neurofeedback, on the other hand, point out that many of the studies are case reports or have serious methodological flaws that cast doubts on their findings. A review of the few studies involving adults with ADHD suggests a middle-ground conclusion that neurofeedback has tentative support. There have been some recent studies of neurofeedback for children with ADHD that used improved research designs.

Computerized working memory training has yielded some positive results in samples of children with ADHD and such training would seem to be helpful for adults, though there have not yet been published reports involving adults with ADHD. However, as with neurofeedback, even if the therapeutic effects are reliable it remains unclear precisely how these interventions work and whether the positive effects generalize to improved functioning in day-to-day life.

Complementary and alternative treatments. There is a wide array of what are deemed “alternative” treatments for ADHD, such as nutritional supplements, specialized exercise programs targeting certain brain regions, dietary approaches, etc. There is preliminary evidence that omega-3 fatty acid supplementation may result in mild improvements in some ADHD symptoms, though these are based on studies of children. Likewise, pilot research of mindfulness meditation suggests it is associated with some improvements for adults with ADHD. There are obvious health benefits of mineral supplementation in cases of identified deficiencies; likewise, exercise, healthy diet, and other good health practices should be part of an overall wellness plan rather than being considered “treatments” for adult ADHD.

There are a number of treatment options for adult ADHD that can be used in combination with medications to target specific areas of impairment. A few of the treatment options have relatively strong support and some others have promising but preliminary evidence for their use while still others have not been found to be helpful. It is important to personalize the combination of treatments to meet the needs of the adult with ADHD in order to optimize functioning and well-being.

J. Russell Ramsay, PhD, is associate professor of clinical psychology in psychiatry and co-director of the Adult ADHD Treatment and Research Program at the University of Pennsylvania Perelman School of Medicine.


Monica Q said...

I am glad to read that more professionals are begining to pay attention to the impact that ADHD has on adults and their families.
My husband grew up with ADHD and was never treated as a child. I first heard of this condition about 12 years ago and immediately recognized all of the symptoms.
ADHD has greately impacted our marriage and family.
What has really negatively impacted our relationship is the lack of emotional empaty although disorganization, poor time management skills, procrastination and lack of patience had made a big dent in our family life.
Out of my 3 grown children, 2 of them show some symptoms but none of them are as affected as my husband.
Please keep researching ADHD in adults who were not treated, most of them are the parents or grandparents of children with ADHD.
Thank you.

Monica Q said...

I am currently looking for a marriage therapist who speciallizes in ADHD in the Houston area.
Our 32 year marriage is at stake.
I will greatly appreciate any suggestions.
It has been really difficult to find qualified psycologists who dominate this subject.
Thank you very much in advance.
Monica Q

Dr. Stella Fernandez said...

Great information Dr. Ramsay. I'm a Clinical Psychologist practicing in the Midwest that provides evaluation and treatment of Adults with ADHD. I have found it difficult to access good basic information for my couples who struggle with the many intricacies involved. Would you suggest the best resources available and/or treatment modalities for such couples that are troubled with the symptoms. Thanks so much.
Dr. Stella Fernandez

Monica Q said...

I wish my husband would have received treatment for ADHD as a child. We have been married for 32 years and are facing hardships caused by it. I wish there were more studies on this dissorder, specially in the emotional intelligence area where he is most affected.
His lack of patience, disorganization, and emotional empaty had negatively impacted our life and taken a toll on our family.
He is on medication but refuses to go to counseling mostly because it is hard to find knowledgeable therapist on this field.
We live in the Houston area, can you recomend a specialist?
Many thanks,
Monica Quijano

alvaro said...

completely useful..good source, thanks anyway!

cb said...

Dr. Ramsay, very significant benefits to ADHD are derived from practice of the Transcendental Meditation program, as shown in this PBS report:

Dr. Craig M. Berg

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