Attention-Deficit/Hyperactivity Disorder

WHAT IS ADHD?

Attention-deficit/hyperactivity disorder (ADHD), formerly referred to as attention-deficit disorder (ADD), is a problem characterized by an inability to focus one’s attention; an inability to control impulses, behaviors, and emotions; and a recurring feeling of restlessness.^1-3 For someone struggling with ADHD, these problems are frequent and prevent the person from completing tasks in a quick and efficient way.⁴

Adults with ADHD typically have a low tolerance for frustration. They are easily distracted at home and at their jobs. They often find it very difficult to read or focus their attention on one thing, so they frequently switch tasks. As a result, others might describe them as restless, as daydreamers, or as people who aren’t detail oriented.

Many people with this problem also often find it hard to control their impulses. For example, they might frequently interrupt others’ conversations or have a history of automobile crashes or other accidents caused by impulsive behavior.⁵ They might also find it hard to remain seated for a long time or to work quietly.

People struggling with ADHD are often restless and forgetful. However, this doesn’t happen because they aren’t trying hard enough or because they’re lazy. It happens because they often find it exceptionally difficult to concentrate on a single thought or topic for more than a few minutes. For adults with ADHD, no amount of willpower is enough to counteract the forces of the disorder. Due to this inability to focus, many people with ADHD perform poorly at school and work despite their qualifications and true abilities.¹

Most adults with ADHD can remember having this problem since they were children. Frequently, they can remember being disciplined for not being able to sit still or finish their schoolwork. And while some people might outgrow these problems or have them become less severe over time, many adults remain burdened with these problems for most of their lives. Some research indicates that as adults with ADHD age, their hyperactive behaviors become less frequent; however, their disorganized behaviors often become more noticeable.^{2, 6}

ARE THERE OTHER PROBLEMS RELATED TO ADHD?

Adults struggling with ADHD often come to a mental health care professional for help with related problems, rather than ADHD itself.^{1, 6} These problems often include anxiety, depression, borderline personality disorder, sleep problems, and substance abuse.⁷

WHO IS AFFECTED BY ADHD?

ADHD is a disorder that affects both children and adults. For adults struggling with ADHD, the problem usually began when they were in preschool or in the early years of elementary school.⁸ It’s estimated that between 3 and 7 percent of school-age children suffer with ADHD,² and boys are affected two to three times more often than girls.⁹ Follow-up studies indicate that 30 to 80 percent of children diagnosed with ADHD continue to struggle with the disorder when they become adults.^10-15 As a result, it’s estimated that 1 to 5 percent of all adults struggle with ADHD.^{3, 16-20}

WHAT CAUSES ADHD?

ADHD research suggests that the cause of the disorder is largely due to biological factors. Brain-imaging studies of people with ADHD have discovered differences in the part of the brain associated with the control of voluntary movements.^{21, 22} Since biological factors like this tend to be inheritable, a person has a greater risk of developing ADHD if a parent has the disorder.^{23, 24} In fact, one study suggested that ADHD has a higher risk of being inherited than any other psychiatric disorder.²⁵

However, just because a person has a genetic likelihood for developing ADHD, this doesn’t mean he or she will necessarily be affected. Some genetic codes are expressed only under certain environmental conditions, such as stress, injury, and toxic environments, which have also been associated with the development of ADHD.²³

WHAT TREATMENTS ARE EFFECTIVE FOR ADHD?

Unfortunately, ADHD in adults isn’t always recognized by mental health care professionals.^{5, 26} As a result, not everyone with the problem will receive proper care. For an accurate diagnosis, people need to provide their clinician with many details of the disorder. Yet, even then, many mental health care professionals will still want to verify that the disorder has existed since childhood before making an official diagnosis.² For this reason, it might be necessary for other family members, especially older family members, to speak with the clinician to verify the diagnosis.

If ADHD is properly identified, there are a number of effective treatments. In children and adolescents, the most common form of treatment is the medication methylphenidate (Ritalin).²⁷ Ritalin is a stimulant, but, ironically, in children and some adults it has a calming effect that relieves many ADHD symptoms.^{28, 29} However, not everyone responds well to Ritalin,³⁰ and some people may find the side effects of the medication to be intolerable. Typical side effects include muscle tics, loss of appetite, and insomnia.⁵ Antidepressant medications such as bupropion (Wellbutrin), imipramine (Tofranil), and the nonstimulant medication atomoxetine (Strattera) are also used to treat ADHD.^{29, 31} (Click here for more information about the use of medications.)

Many people with ADHD may also find psychotherapy helpful, especially those for whom medication is ineffective or intolerable. Psychotherapeutic treatments for adults with ADHD typically focus on two goals: creating strategies to manage the symptoms of ADHD, and learning how to cope with the emotional impact of the disorder.^{32, 33}

In general, treatments that provide little interaction between a person and his or her psychotherapist probably won’t be effective in treating ADHD.³⁴ Typically, people with ADHD need interactive, structured therapies to help them stay focused on their thoughts and tasks. For example, cognitive behavioral therapy has been shown to be an effective ADHD treatment in a number of studies.^35-38 The people treated in these studies were able to improve their organization and time-management skills, as well as examine and partly change the way they think and feel. Similarly, a version of dialectical behavior therapy, modified specifically to treat ADHD, has also proven to be an effective treatment.¹

COGNITIVE BEHAVIORAL THERAPY FOR ADHD

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. When used By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.

The CBT treatment for ADHD is often composed of eight steps:^39-41

Conduct an assessment and provide education
Develop practical life skills
Develop problem-solving skills
Challenge and correct self-defeating thoughts
Develop healthy habits
Develop effective communication skills
Develop relaxation skills
Prevent relapse

1. Conduct an Assessment and Provide Education

The first step of the cognitive behavioral treatment for ADHD is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with ADHD and not some other, similar problem. Because ADHD is largely a biological problem, it’s very important for those struggling with symptoms of ADHD to consult with a medical professional as soon as possible, in order to be assessed for proper medication management. In this respect, the disorder is similar to diabetes and other medical illnesses that must be treated over the course of a person’s lifetime. After being stabilized on medication, a person may find it helpful to use the other skills highlighted below in order to create a healthy lifestyle. (Click here for more information about medications for ADHD.)

Once people are diagnosed with ADHD, it’s important that they understand the basic nature and causes of the disorder, as highlighted above). (Click here for more information about ADHD.)

Since ADHD frequently disrupts a person’s family and social relationships, it’s also very important to educate family and friends about the nature of the disorder and the roles they might play in helping to stabilize the problem. This includes understanding the nature of the disorder and the events that can trigger ADHD episodes, and learning how to communicate more effectively. (Click here for more information about educating family members about ADHD.)

It’s also important for everyone involved to understand that CBT is an active form of treatment that requires the person with ADHD and his or her loved ones to do work outside of the therapy session. (Click here for more information on assessment and education for ADHD.)

2. Develop Practical Life Skills

For people struggling with ADHD, daily activities often become a chore due to an uncontrollable lack of focus and excessive restlessness. For these reasons, learning how to plan and achieve practical goals can make life easier and more fulfilling. For example, some people with ADHD often benefit from using organization and planning tools, such as calendars, day planners, and alarm clocks, to help them stay focused on their tasks. Similarly, other people might benefit from skills designed to help them improve their memory, manage their time more effectively, get their lives organized, and stay focused on their goals. (Click here for more information on developing life skills to help with ADHD.)

3. Develop Problem-Solving Skills

Often, the next step of the treatment for ADHD is to learn problem-solving skills. Sometimes people with ADHD lack coping skills for handling difficult or uncertain situations. This can lead to feelings of anxiety, anger, and frustration. Problem-solving skills can help the person identify and select healthy solutions to difficult, anxiety-provoking situations. The steps to problem solving include defining the problem, outlining the desired goals, brainstorming possible solutions, evaluating the possible consequences, putting the chosen plan into action, and evaluating the results. This is a very effective skill when used alone by the person with the disorder, and it can be even more powerful when used cooperatively with the person’s family and friends. (Click here for instructions on problem solving.)

4. Challenge and Correct Self-Defeating Thoughts

The next step of the cognitive behavioral treatment for ADHD is to challenge and correct self-defeating thoughts. This is a very important step for three reasons: First, self-critical thoughts can often lead to feelings of anxiety, anger, and frustration, which are often associated with ADHD. Second, self-defeating thoughts often play a large role in the development of depression, which often accompanies ADHD. Therefore, this step is at the core of the CBT treatment for depression, too. And third, self-defeating thoughts often cause a person to stop taking medications. For example, a person might think, “Why bother taking them if I’m going to have the problem for the rest of my life?” or “I’m feeling better now, so I don’t have to take my medications anymore.” For all of these reasons, challenging and correcting self-defeating thoughts is a crucial step in the CBT treatment for ADHD.

Automatic thoughts are the most observable form of self-defeating thoughts. These are critical thoughts that people think and say to themselves that sabotage success and happiness. Two examples of automatic thoughts might be “I don’t deserve anything good happening to me” and “Why bother trying? I’m just going to fail.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels sad or hopeless. (Click here for information on identifying automatic thoughts.)

Much of the CBT treatment for ADHD will be spent identifying and reevaluating these types of thoughts. This can be done with the use of a thought record. The thought record helps the person look for evidence that both supports and contradicts these thoughts. Then, most importantly, it helps the person create a more balanced thought. For example, if the person struggling with ADHD had the thought “Why bother trying? I’m just going to fail,” the thought record would offer evidence of this thought being true and examples of it not being true in the person’s life.

The thought record also helps the person identify different types of cognitive distortions, unhelpful thinking styles that generate those automatic thoughts. For example, overgeneralizing involves making broad negative conclusions about life based on limited situations, and minimizing and magnifying involve discounting the positive and enlarging the negative aspects of life. (Click here for information on identifying cognitive distortions.)

By evaluating the evidence and cognitive distortions, the goal of the thought record is to help the person find a new, more balanced thought and ease feelings of sadness and hopelessness. In this example, perhaps a more balanced thought would be “Even though I don’t do everything perfectly, I’m still capable of doing most things pretty well.” And instead of feeling excessively sad, such as 8 on a scale of 1 to 10, perhaps this newer thought will help the person feel less sad, say only a 5 out of 10. (Click here for instructions on using a thought record.)

As the work on challenging automatic thoughts continues, a person using a thought record will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make a person more vulnerable to anxiety, frustration, and depression. These core beliefs, often called schemas, include thoughts like “I’m a failure,” “I’m worthless,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought record and other techniques. (Click here for instructions on challenging core beliefs.)

5. Develop Healthy Habits

Many people who struggle with ADHD engage in habits that make their lives more difficult, such as avoidance, procrastination, juggling multiple projects, and rushing to finish tasks. Obviously, habits such as these need to be addressed. In addition, those struggling with ADHD often need help developing healthy habits that can make their lives feel more fulfilling, such as exercising, eating well, sleeping well, and relaxing. They might also need help finding a job that fits their personality and characteristics. (Click here for instructions on developing healthy habits.)

6. Develop Effective Communication Skills

Many people with ADHD have difficulty making requests to get their needs met in fair and reasonable ways. Assertive communication skills can be very effective for making these requests. In addition, problem-solving communication skills are excellent for helping people in the following situations: setting limits with others, listening to others in effective ways, interpreting others’ body language, negotiating with others, and dealing with criticism. (Click here for instructions on developing effective communication skills.)

7. Develop Relaxation Skills

Many people experience stress in their daily lives, but for people with ADHD, stress can sometimes trigger anger, frustration, and impulsivity. This is because stress, particularly chronic stress, takes a very heavy toll on a person’s body, mind, and relationships.

Relaxation exercises can help reverse some of these effects, but more importantly, they can also prepare a person to confront the causes of stress in a much healthier way. For example, suppose a woman’s relationship with her husband has been problematic. For the last few years, she has avoided dealing with the conflicts, and as a result she has developed many physical symptoms of stress, such as tight muscles and high blood pressure. Practicing relaxation techniques in a consistent way can help ease these problems. In addition, they can also help if she chooses to address the relationship issues with her husband. Relaxation techniques can prepare a person for confronting stressors and help the person deal with problems in a more effective way.

Typically, relaxation exercises begin with building body awareness to help people scan their bodies for signs of stress and muscles tension. (Click here for instructions on building body awareness.)

Next, it’s very important to learn proper breathing techniques. Many people who are under stress breathe in a very constricted way. Some of them breathe very rapidly. Either of these types of breathing can make a person more vulnerable to stress. Learning proper breathing technique, using long, slow breaths, can help a person relax quickly and easily. (Click here for instructions on proper breathing techniques.)

Progressive muscle relaxation is also a very important exercise. Many people experience stress as muscle tension. Progressive muscle relaxation helps people relax the entire body. Then, once this basic technique is established, people can learn to relax even more quickly by using cue-controlled relaxation and other rapid relaxation techniques. (Click here for instructions on using muscle relaxation techniques.)

Meditation is also helpful for many people. Learning how to stay focused in the present moment is a healthy alternative to being overwhelmed by stress-provoking thoughts. Meditation, or mindfulness, can take many forms, none of which have to be spiritual. People can learn to be mindful of their breathing, to meditate while walking or eating, or to use visualization to meditate. (Click here for instructions on building meditation and mindfulness skills.)

Effective relaxation also includes developing good nutritional habits and engaging in healthy physical exercise. Therefore, the person should make time in his or her life to address these issues, too. (Click here for instructions on developing good nutritional habits and physical exercise regimens.)

Visualization techniques use the power of the imagination to help people relax and create mental space for evaluating stressful situations. Techniques such as special-place visualization can help people relax by imagining a safe place in their mind, where they can completely relax. (Click here for instructions on using visualization and special-place techniques.)

8. Prevent Relapse

Finally, the last step of the cognitive behavioral treatment for ADHD is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of anxiety and frustration in order to take steps to prevent them from interfering with the person’s life. And when needed, people should always consider seeking additional help from medical and mental health care professionals.

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