Stimulate the Brain: Not Just Stimulants
Non-pharmacological Treatment of Attentional Disorders (ADD/ADHD) in Adults
by Consultant Psychiatrist Dr Sameer P. Sarkar, MD, FRCPsych
Diplomate, American Board of Psychiatry and Neurology, Inc.
“Every day we are confronted with the impossibility of making up the difference between the hopes and dreams of our patients and what we can realistically provide.”- Margaret Weiss, Clinical Professor, University of British Columbia
The National Institute of Clinical Excellence regularly publishes technology evaluations and ‘guidance’ (NICE Guidelines). Although they are ‘guidelines’ only and not gospel, many consider them to be so, perhaps because no other guidelines exist to clinicians which they can rely on as ‘benchmark’. The NICE guidelines on ADHD conceptualizes the disorder to be across ‘life-span’, i.e. not limited to a particular age-group. In that guideline, NICE considers CBT based therapy to be an important complementary treatment for adults with ADHD.
Whether ADHD is a neurodevelopmental disorder or a disorder of brain chemicals is not entirely clear. What is clear however is that the presentation between ADHD in Children and in Adults differs, sometime significantly. Experts do not agree if Adult ADHD is a graduation from Child ADHD or it is a late onset ADHD which manifests in adulthood. Up to two-thirds of ADHD children continue to suffer with symptoms into adult life, many of whom experience residual problems which warrant treatment. In addition, there are many young people who do not receive a diagnosis until they are adults in spite of having presented on numerous occasions to health services, and increasingly, in the Criminal Justice System.
Although ADHD is a complex disorder, the main problems are mainly impairing/invalidating degree of inattention, hyperactivity, and impulsivity. Together, with or without hyperactivity the overall presentation is once of disorganization, being ‘scatty’, an ‘airhead’, a ‘daydreamer’, or less charitably (but more commonly) ‘lazy’ or simply ‘stupid’. Until very recently in UK and much of Europe, adult ADHD diagnosis was frowned upon, mocked sometimes as the patient being too ‘Americanized’. For whatever reason, psychiatrists were reluctant to diagnose ADHD in adults perhaps for the fear of medicalizing laziness or other constitutional problems. ADHD sufferers achieve less in almost every domain of their life and most do not come to our attention until there is a significant ‘ultimatum event’, either at work, college, in relationships, or worse still, in the criminal justice arena. By ‘ultimatum event’ I mean that the situation has become so dire that ‘unless you do something, it’s [insert the situation] over’. Faced with the inevitable but impossible choice ‘between a rock and a hard place’, many gravitate towards the physician, the psychiatrist. In case of the alcohol dependent patient, we would often hear about the ‘last chance saloon.’ Ironically, seeking or accepting treatment becomes the ADHD sufferers ‘last chance saloon’.
It is uncommon for ADHD to present itself alone. Often there are other co-morbid conditions. These range from depression, anxiety, adjustment disorders, substance abuse to neurological disorders such as tics, or rarely, Tourette’s.
As a consequence, the assessment of ADHD symptoms cannot occur in a vacuum and must be considered as part of a comprehensive assessment process.
Any treatment plan for ADHD therefore must be based on a comprehensive diagnostic evaluation: the clinician should be able to document that the patient
meets the criteria for a diagnosis of an ADHD (subtypes are not as important as they are in children), being aware of possible concomitant medical or psychiatric conditions. This is where a medical doctor (MD) is of tremendous value. Symptom-based assessment is a framework to knowing how to help someone get better at day-to-day living. The real challenge of helping patients is to target the areas where they have problems. This is why, all modern assessment tools focus on disruptions in clean-cut ‘domains’ or areas of life affected, and the degree of such impairments.
Once the diagnosis is established, the next consideration is the treatment. Gold standard evidence (Randomized Controlled Trial or RCT) on the effects of medicines in adults is far smaller than in children. No traditional stimulant medicine (Modafinil or Provigil ® is but it is hardly a ‘proper’ stimulant) is licensed for use in adults with ADHD in the UK. This I consider to be more of an idiosyncratic nonsense from the regulators in UK, rather than based on scientific wisdom because the results of these trials have consistently demonstrated the effectiveness of stimulants to reduce the level of ADHD symptoms in adults diagnosed as suffering from ADHD.
Among the vast plethora of non-pharmacological treatments practiced, traditionally Psychoeducation used to be the basis of every treatment, especially in children even though the effects of psychoeducation have not been well evaluated. In children, school based behavioral interventions are known to be the best established psychosocial interventions (and tested empirically) but the effects of peer-focused behavioral interventions (and social skills trainings) and cognitive behavioral therapy (CBT) of the patient have not been that well researched. A combination of several of these interventions is often required since each of these interventions has its own particular strengths and treatment objectives. This combined treatment is also often called multimodal psychosocial treatment.
Most of the evidence for non-pharmacological treatments, slim picking as they are, is for Cognitive Behavioral Therapies (CBT), which aim to promote ‘self-controlled behavior’ through the enhancement of ‘problem-solving’ strategies.
Predictably several different types of cognitive behavioral treatments have been invented aimed at helping children with ADHD. These include a variety of techniques such as verbal self-instructions, problem-solving strategies, cognitive modelling, self-monitoring, self-evaluation, and self-reinforcement. Unhappily, although a lot of research has been conducted using these different types of cognitive-behavioral interventions no clinically important changes have yet been demonstrated on either behavioral measures or academic performance in children with ADHD.
There is however limited evidence that a clever combination of social skills training and problem-solving interventions can lead to positive effects but, wait for it, only if they are combined with intensive, multicomponent behavioral treatment packages. This makes the treatment sound more daunting than it actually is. It also sounds more expensive.
Improving or helping core skills of executive functioning is a recent Approach which also happens to be my personal favorite. In recent years there has been growing awareness for the need for non-pharmacological treatment options for adults with ADHD of which a great proportion do not show ‘significant’ or satisfactory symptom reduction with medication alone. Some may even be unable to tolerate ADHD medications.
Adults requesting treatment for ADHD usually have complex problems extending well beyond the core ADHD symptoms and they are unlikely to respond to ADHD
Medication only. Non-pharmacological treatments for adults with ADHD include counseling, coaching and individual or group cognitive-behavioral
therapy. None of these have an extensive evidence base of effectiveness beyond personal preferences or anecdotal evidence. Counseling and psychoeducation (either individually or in group setting) has considerable conceptual overlap with cognitive-behavior therapy. Patients (with or without family or significant others) receive information about ADHD and are taught strategies to meet their individual goals.
‘Coaching’ is defined as a supportive and pragmatic process. The patient and their personal coach work together, usually via short daily telephone calls, with the aim of identifying goals and to developing
strategies to meet them. There is no standard methodology and no research has been done on this form of intervention in any problems let alone for adults with ADHD and it has taken some PR hits, calling it nothing but a fad, an ornamental status enhancer and personal coaches have been busy re-branding themselves as ‘Life Coach’.
Recent research by psychologists have also demonstrated that CBT for adults with ADHD is ‘highly effective’. As psychological treatment of ADHD is very much in its infancy, this is a rather tall claim. The early and relatively methodologically unsound studies of psychological treatment did however consistently show improvement in symptoms, improvement in skills and improvement in productivity. The focus of treatment for ADHD has traditionally been on symptoms rather than functioning. Although DSM-V requires there to be ‘impairment’ before a constellation of symptoms can be regarded as a disorder, early treatment methods somehow managed to confuse symptom improvement with reduction of impairment. Symptom relief through a particular treatment is of course a ‘no-brainer’, but as we know, especially in the particularly contentious branch of medicine that is psychiatry, one man’s symptom relief is another man’s oppression. Whereas Improving functioning and thence quality of life as a whole not so much. That is why me personally, and many clinicians like myself focus on achieving full or near-full functioning as the treatment goal, not just symptom relief. I call this ‘You, Maximized’.
Patients with adult ADHD (or any attentional disorder for that matter) will enter therapy either thinking about medication, or be on medication. Some will have failed one drug treatment or other. Any psychological treatment therefore has to help them integrate the experience of taking a pill to assist with focus and restraint. An effective treatment needs to capitalize on the strength and limitations of the benefits through medication. ‘Seeing the wood for the trees’ is a talent that underlies both the strength and the general weakness of cognition in the patient with attentional disorders.
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 Dr Sarkar is a Consultant Psychiatrist and Forensic Psychiatrist entirely in private practice. His practice is limited to treatment of Attentional Disorders, Mood Disorders and Cognitive Remediation and Enhancement