Psychosocial Interventions for ADHD in Adults: A Guide for Primary Care Providers J. Russell Ramsay, Ph.D. Associate Director, ADHD Treatment and Research Program Assistant Professor of Psychology in Psychiatry Department of Psychiatry University of Pennsylvania School of Medicine This activity is supported by an educational grant from Lilly USA, LLC. For further information concerning Lilly grant funding visit, www.lillygrantoffice.com
2 Faculty Disclosure Dr. Ramsay has no relevant financial relationships with commercial interest in any amount that would create a potential conflict of interest.
3 Learning Objectives After completing this module, participants will be able to: identify psychosocial treatments for adults diagnosed with ADHD make referral suggestions for appropriate psychosocial treatments for adults with ADHD based on their presenting complaints
4 Commonly encountered questions The medications are helping me but I m still having problems. What else can I do? I ve tried ADHD medications. Is there something else that can help me with my ADHD?
What are psychosocial interventions for adult ADHD? 1 5 Psychosocial interventions are nonmedication treatments and related support services designed to reduce impairment and improve coping skills in adults with ADHD 1. Ramsay (2010). Nonmedication treatments for adult ADHD. Washington, DC: APA.
What are psychosocial interventions for adult ADHD? 1 6 Psychosocial interventions include: Psychoeducation Cognitive Behavioral Therapy Educational accommodations Employment accommodations Treatments for relationship difficulties (e.g., couples of family therapy) Financial management 1. Ramsay (2010). Nonmedication treatments for adult ADHD. Washington, DC: APA.
When are psychosocial treatments appropriate for adults with ADHD? 1 7 Ongoing coping difficulties despite an otherwise effective medication regimen Medical profile (e.g., cardiac) or adverse side effects obviates the use of medications Patient refuses medications despite adequate education that addresses concerns 1. Ramsay (2010). Nonmedication treatments for adult ADHD. Washington, DC: APA.
How can psychosocial treatments help my adult patients who have ADHD? Psychosocial treatments are helpful when patients face: Residual ADHD symptoms and impairments Educational difficulties 1 Occupational difficulties 2 Relationship difficulties 3 Financial difficulties 3 Co-existing psychiatric diagnosis (e.g., mood, anxiety, substance use) 4 Any major impairment in adult role functioning associated with incompletely treated ADHD 8 1. DuPaul et al. (2009). Journal of Attention Disorders, 13, 234-250. 2. Nadeau (2005). Journal of Clinical Psychology: In Session, 61, 549-563. 3. Robin (in press). Lifestyle and family problems of older adolescents and adults with AD/HD. In Goldstein & Naglieri (Eds.), Learning and Attention Disorders in Adolescence and Adulthood. New York: Wiley. 4. Ramsay (2009). Current Attention Disorder Reports, 1, 85-91.
9 Psychoeducation 1,2 Teach patient and family about ADHD Overview nature, course of ADHD Overview of treatment options and potential effects/side effects Instill hope and optimism 1. Ramsay (2010). Journal of Cognitive Psychotherapy, 24, 37-45. 2. Sprich et al. (2010). Cognitive and Behavioral Practice, 17, 9-15.
10 Cognitive Behavioral Therapy (1) What is Cognitive Behavioral Therapy (CBT)? 1 Model of psychotherapy emphasizing the role of distorted information processing (i.e., distorted thoughts) on the development and maintenance of depression and anxiety Focus on the interplay of thoughts, behaviors, and emotions and their influence on current functioning Strong empirical support as a psychological treatment or adjunct for a variety of psychiatric disorders 1. Beck (2005). Archives of General Psychiatry, 62, 953-959.
Cognitive Behavioral Therapy (2) 1,2 11 Cognitive behavioral therapy (CBT) has been modified to address adult ADHD Structured sessions and treatment goals Organization and planning Time management Procrastination Coping with distractibility Delivered in either group or individual format Interventions target functional impairments associated with ADHD as well as co-existing problems Behavioral (e.g., modify self-defeating behaviors) Cognitive (e.g., cognitive modification of distorted thoughts) Emotional management (e.g., frustration, anger, anxiety, depression) 1. Ramsay & Rostain (2008). Cognitive behavioral therapy for adult ADHD. New York: Routledge. 2. Safren et al. (2005). Mastering your adult ADHD. New York: Oxford University Press.
12 Cognitive Behavioral Therapy (3) 1,2 CBT approaches for adult ADHD target: the development and maintenance of coping skills to address the areas of impairment associated with symptoms of ADHD (e.g., disorganization, time management, procrastination), thereby improving overall well-being. dysfunctional thought patterns that lead to excessive selfcriticism, pessimism, or a maladaptive positive bias, all of which may interfere with motivation and follow through on the use of coping skills. co-existing problems that may further interfere with coping with ADHD, such as anxiety, depression, or substance use problems. 1. Knouse & Safren (in press). Psychiatric Clinics of North America. 2. Ramsay (2010). Journal of Cognitive Psychotherapy, 24, 37-45.
13 Cognitive Behavioral Therapy (4) CBT approaches, in both individual and group formats, have produced consistently positive results in several clinical outcome studies of the treatment of adults with ADHD 1,2,3,4, including randomized control studies. 5,6 1. Knouse & Safren (in press). Psychiatric Clinics of North America. 2. Knouse et al. (2008). Expert Review of Neurotherapeutics, 8, 1537-1548 3. Ramsay (2009). Current Attention Disorder Reports, 1, 85-91. 4. Ramsay (2010). Nonmedication treatments for adult ADHD. Washington, DC: APA. 5. Safren et al. (2005). Behaviour Research and Therapy, 43, 831-842. 6. Solanto et al. (2010). American Journal of Psychiatry, AiA, 1-11.
14 Cognitive Behavioral Therapy (5) Commonly encountered question: How is cognitive behavioral therapy going to help me? I know what I need to do but just cannot do it.
15 Educational Accommodations (1) 1,2,3 College students with ADHD may be eligible for academic accommodations Requirements for documentation: Recent psychoeducational evaluation performed by qualified professional Documented signs of significant impairment that interferes with learning in an otherwise qualified student 1. Gregg (2009). Adolescents and adults with learning disabilities and ADHD. New York: Guildford. 2. Latham & Latham (2009).Learning disabilities, ADHD and the law in higher education and employment. Washington, DC: JKL Communications. 3. Mapou (2009). Adult learning disabilities and ADHD. New York: Oxford University Press
16 Educational Accommodations (2) 1,2,3 A diagnosis of ADHD alone is not sufficient for accommodations there must be evidence of impairment that affects learning Common academic accommodations for ADHD include: Extended time on exams Alternate exam format Testing in reduced-distraction room Access to lecture materials/slides prior to class Note-taking service Course substitution (e.g., foreign language) Texts in audio format Reduced course load, extended graduation time line 1. Gregg (2009). Adolescents and adults with learning disabilities and ADHD. New York: Guildford. 2. Latham & Latham (2009).Learning disabilities, ADHD and the law in higher education and employment. Washington, DC: JKL Communications. 3. Mapou (2009). Adult learning disabilities and ADHD. New York: Oxford University Press.
Educational Accommodations (3) 1 17 Students with ADHD may benefit from specialized learning support or academic coaching Learning support services help ADHD students: Develop and implement effective learning strategies Use coping skills to address time management and organization problems that may affect academics Use assistive technologies (e.g., consistent use of organizational features of cell phone, computer, PDA, voice-activated software for writing, etc.) 1. Ramsay (2010). Nonmedication treatments for adult ADHD. Washington, DC: APA.
18 Educational Accommodations (4) There is promising pilot research that academic coaching is helpful for college students with ADHD 1,2,3,4 Common features of programs studied: Identification of ADHD and coping skill deficits Specialized support that targets Individualized learning support related to current courses Use of coping skills emphasizing implementation of study skills, organization, and time management strategies Independent use of coping skills and positive alliance with coach strongest predictors of improvements 3,4 1. Allsopp et al. (2005). Learning Disabilities Research & Practice, 20, 103-118. 2. Prevatt (2009). Journal of Attention Disorders Online First. 3. Swartz et al. (2005). Psychology in the Schools, 46, 647-656. 4. Zwart & Kallemeyn (2001). Journal of Postsecondary Education and Disability, 15, 5-20.
19 Educational Accommodations (5) Commonly encountered question: Should I disclose my diagnosis to my school?
20 Employment Accommodations (1) 1 Otherwise qualified workers with ADHD may be eligible for workplace accommodations if significant functional impairments affecting work performance can be documented 1 There are many informal accommodations and coping strategies that can be implemented without disclosure of the ADHD diagnosis What else can I do? 1. Latham & Latham (2009). Learning disabilities, ADHD and the law in higher education and employment. Washington,DC: JKL Communications.
21 Employment Accommodations (2) 1,2 ADHD Coaching is an emerging psychosocial support service that may be helpful in workplace functioning 1 ADHD coaches focus on helping adults with ADHD to develop and implement coping skills that can be used to improve work efficiency ADHD coaching is still defining itself as a field and there is one efficacy study with positive results for adults with ADHD 2 1. Ramsay (2010). Nonmedication treatments for adult ADHD. Washington, DC: APA. 2. Kubik (2010). Journal of Attention Disorders, 13, 442-453.
22 Employment Accommodations (3) 1 Employment accommodations include: 1 Computer software (e.g., voice-activated software) Books and manuals in audio format Dictation service Frequent meetings with boss to track project tasks Break down large projects into individual tasks Modification of job demands Quiet work space Written reminders of task assignments 1. Mapou (2009). Adult learning disabilities and ADHD. New York: Oxford University Press.
23 Employment Accommodations (4) Commonly encountered question: Should I tell my employer that I have ADHD? During interview process? After being hired?
24 Employment Accommodations (5) Vocational rehabilitation and vocational counseling Indicated in cases of severe, chronic employment problems Targets job finding and job maintenance skills Often provides ongoing support and communication with employer during employment
Treatments for Relationship Difficulties (1) 1,2 25 Adult ADHD may create problems in relationships: 1 Marriages / committed relationships Parenting Co-workers Friendships There have been no outcome studies of marital/couples or family treatments that focus on the role of adult ADHD 2 It is helpful to find a clinician experienced with adult ADHD 1. Barkley et al. (2008). ADHD in adults. New York: Guilford. 2. Ramsay (2010). Nonmedication treatments for adult ADHD. Washington, DC: APA.
Treatments for Relationship Difficulties (2) 1,2,3 26 Common interventions for relationship difficulties involving an adult with ADHD include: 1,2,3 Accurate diagnosis and treatment for adult ADHD Communication skills training Increase positive communication Decrease negative communication Problem-solving skills training Cognitive modification of unrealistic expectations Relationship enhancing activities 1. Kilcarr (2002). Making marriages work for individuals with ADHD. In Goldstein & Ellison (Eds.), Clinician s guide to adult ADHD. San Diego, CA: Academic Press. 2. Phelan (2002). Families and ADHD. In Goldstein & Ellison (Eds.), Clinician s guide to adult ADHD. San Diego, CA: Academic Press. 3. Robin (2006). Training families with adolescents with ADHD. In Barkley (Ed.), Attention Deficit Hyperactivity Disorder. New York: Guilford.
Strategies for Financial and Money Management 1,2 27 Outsource financial matters Set up electronic systems for finances Paying bills Automatic deposit in retirement plan or savings account Tracking income and spending Use consultant before spending (e.g., spouse) Coping skills for financial behaviors CBT for cognitive and emotional issues around money Coping strategies for spending problems (e.g., 24 hour delay) Set up weekly time for budgeting, paying bills, etc. 1. Robin (in press). Lifestyle and family problems of older adolescents and adults with AD/HD. In Goldstein & Naglieri (Eds.), Learning and Attention Disorders in Adolescence and Adulthood. New York: Wiley. 2. Tuckman (2009). More Attention, Less Deficit. Plantation, FL: Specialty Press.
Treatment options for severe 28 emotional and functional comorbidities In cases of persistent emotional problems (e.g., anxiety and/or depression, anger management, selfesteem issues), individuals may be referred for either group or individual psychotherapy (including CBT) targeting the relevant emotional issues. In cases of persistent executive control deficits, in addition to reappraisal of pharmacotherapy options, individuals may be referred for more in depth neurological testing, possible cognitive rehabilitation, and family treatment. 1 1. Oddy & Worthington (Eds.)(2009). The rehabilitation of executive disorders. Oxford: Oxford University Press.
Psychosocial Treatments for Adult 29 ADHD: Summary (1) Useful adjunct to medications Available outcome studies of cognitive behavioral therapy and academic coaching for adult ADHD have provided evidence of their efficacy Can be used in cases in which medication treatment is ineffective or contraindicated Are relevant in various settings (e.g., school, work, social)
Psychosocial Treatments for Adult 30 ADHD: Summary (2) Psychosocial treatments for adult ADHD may be provided by: psychologists and other mental health professionals ADHD coaches university disability and learning support specialists family and couples therapists vocational rehabilitation counselors
31 Thank You