Here, There and Everywhere: Adult ADD

Hal Wallbridge, Ph.D., C.Psych.

Julie Beaulac, Ph.D., C.Psych.

Session Objectives

1. Provide an overview of the challenge in accurately diagnosing ADD in adults

2. How a diagnosis of Adult ADD is made

3. Tips for managing patients with attention problems

4. Non-pharmacological treatment strategies for Adult ADD and attention difficulties more generally

Adult ADD Referrals Many patients are referred for assessment of

ADD (56 referrals on waitlist: 40% question ADD)

Level of disability associated with these patients is generally light, relative to other mental health issues

ADD symptoms are difficult to distinguish from common personality traits, therefore, the diagnosis of adult ADD is very hard to make (to both confirm or to rule out)

ADD: Quick Review

Maladaptively high levels of impulsivity, hyperactivity and inattention

ADD was originally identified as a neurodevelopmental disorder in childhood; later extended to adults

In adults, the inattention component is seen as more prominent

Adults complain of disorganization, lack of sustained effort and failure to accomplish goals

ADD: Quick Review

Prevalence in children is around 5% of the population (rate depends on severity)

Rate in adults has been estimated to be about two thirds of the child rate (3%-4%)

Etiology is uncertain: there is evidence for genetic, environmental, and psychosocial factors

Associated Issues

Educational and occupational difficulties Increased substance abuse Criminal behaviour Mental health conditions: mood disorders,

anxiety disorders, personality disorders

Key Aspects of Diagnosis

The presence of the core problems of inattention, hyperactivity and impulsivity

Long duration of symptoms beginning in childhood

Pervasive impact leading to below normal adjustment

Symptoms not explained by some other condition (what about comorbidity?)

Assessment

Clinical interview Rating scales* (e.g., Brown Attention Deficit Disorder

Scale; Brown, 2001)

Psychological testing Cognitive/attention Psychoeducational Diagnostic**

* We rarely use these** Rarely recommended, but we routinely use

Case Example

29 yr-old single female, university student c/o procrastination, trouble focussing, disorganization, which she

mainly attributed to depression “My problem is not being able to accomplish what I want to do no

matter how hard I try or how driven I am to do so” High grades as a child, but now failing school; can’t read her text

books Tends to quit jobs because bored 2 suicide attempts in past, chronic back pain Involved in competitive sports, supportive family, no drugs/alcohol,

but 50-100 mg caffeine/day to help concentration

Case Example: Testing Results WAIS-IV: average to high average CPT-II: “non-clinical” confidence index, but

evidence of impulsivity CVLT-II: good performance REY: some impulsivity PAI: thinking problems, negative thoughts,

health worries, relational problems, self-doubts

Case Example: Outcome

History and testing “support a diagnosis of attention deficit disorder”

Prescribed Ritalin by psychiatrist with good response for attention symptoms: improved grades

She continues to struggle with back pain due to a degenerative condition, with treatment by opiates

She continues to struggle with negative thinking and doubts about her career path

Requested extensive documentation to obtain accommodations to write MCAT, which I denied her

Diagnostic Challenges

ADD is very difficult to diagnose Range of symptoms is more restricted (trait-like) There is no distinct profile on testing

Many non-ADD patients do poorly on attention testing ADD patients might do well on attention testing

Expectancy effects on self-report and treatment efficacy are large

The symptoms are over determined Unlike many mental health conditions, you can’t really

tell if someone has ADD by interacting with them in a clinical setting

What we say to patients

Themes:1. Try not to get too hung up on a getting a

diagnosis: “You might have ADD, it is difficult to be sure”

2. We suggest that you consider your problems and frustrations as more multidetermined.

The overall goal is to try to encourage the patient to adopt a less simplistic and restrictive way of explaining their difficulties

Observations from Years of Cases We are rarely, if ever, sure about the

diagnosis The biggest predictor of a tentative ADD

diagnosis is the patient thinking they have it We are very unlikely to link ADD alone with

significant disability (with exception of academic difficulties)

We still don’t really know the difference between ADD and personality traits

ADD and Personality

The Big 5 Broad-based factor-analytic model of personality

structure; very popular in psychology Neuroticism – (sensitive/nervous vs. secure/confident) Extraversion – (outgoing/energetic vs.

solitary/reserved) Openness to experience – (inventive/curious vs.

consistent/cautious) Agreeableness – (friendly/compassionate vs.

cold/unkind) Conscientiousness – (efficient/organized vs. easy-

going/careless)

Conscientiousness

High Conscientiousness: Self-discipline, carefulness, thoroughness, organization, deliberation, better impulse control, need for achievement, orderly, industrious

Low Conscientiousness: Procrastination, impulsivity, lower success at school and work, more substance abuse, more antisocial behaviour

Conscientiousness and ADD

Are the characteristic features of ADD the result of a neurodevelopmental brain disorder originating in childhood or simply the result of the person being at on one end of a personality dimension found in the normal population?

Of course, some could argue that conscientiousness emerged in Big 5 research because of the prevalence of ADD in the normal population.

Managing Patients with Attention Problems

Co-existing Conditions

Assess for co-existing conditions (e.g., substance use, depression, anxiety, relationship/work stress)

Some Questions to Ask: Age on onset of attention difficulties? Times when attention difficulties have been better? Worse? What is the impact of attention difficulties at work? Home?

With family/friends? (Assessing for at least moderate impairment across 2+ areas)

How’s your mood? Are you a worrier? How is work? Do you enjoy it? How are your relationships? What substances are you using?

Co-existing Conditions

Manage co-existing conditions

Discuss diagnostic challenge with patients

Discuss options for assessment (public vs. private practice)

Treatment Options

Encourage immediate treatment of attention and co-morbid conditions

Self-management

Community-based resources (e.g., self-help organizations, counselling)

Medication

CBT (most evidence, including for many co-existing conditions); mindfulness-based approaches also likely useful

Non-Pharmacological Treatment Strategies

Psychological Self-Help Workbook for Adults with Attention Problems Pre-assessment Section 1: Reflection and life examination Section 2: Goal Setting Section 3: Organization and Planning Skills Section 4: Reducing Distractibility Section 5: Problem-Solving Section 6: Practice the Skill of Focusing Section 7: Become More Present and “World Aware” Section 8: Balance Your Emotions Section 9: Interpersonal Issues Section 10: Living Well Post-assessment

Life Reflection

Values Assessment

Thinking about the different areas of life (e.g., relationships, work, health, leisure), are there areas in your life that you feel are not in line with your values? How would you like to be in your different relationships? What type of work you would like to do?

Goal Setting

Make goals specific and concrete

Make goals important

Set realistic goals; start small and gradually increase

Schedule goals, write them down, share with others

Review goals often

Problem-Solving

1. Identify the problem

2. Brainstorm and list a variety of possible solutions

3. List the pros and cons of possible solutions

4. Choose the best option and make a plan for how you will put it into action.

5. Consistently apply that strategy for a period of time to see if it is helpful.

6. If the first strategy is not helpful, consistently apply the second possible solution for a period of time to see if it is helpful. Continue these steps until you find a solution that can be most helpful to you

7. Reward yourself when you complete a task.

Other Strategies

Living Well: Physical activity Healthy eating Sleep Leisure

Focusing/Mindfulness (e.g., Mindful breathing)

Organization & planning skills

Reducing distractibility

Referral for a Psychological Assessment When not to refer:

Pt simply asks for a referral or is curious (should go to private practice, not hospital consultation service)

Pt reports a consistent history of symptoms, no other obvious contaminating factors, and they are a candidate for a trial of medication (e.g., in school)

Pt has many reasons for inattention and a clear diagnosis is unlikely: encourage to go straight to counseling

Referral for a Psychological Assessment When to refer:

You are working actively with a patient and you could really use a psychological assessment of them

Pt can’t be reassured or problems can’t be addressed in a reasonable time frame: pt is complicated and difficult

You suspect ADD is likely and pt is a student who may need documentation

Some References

NICE. Attention deficit hyperactivity disorder. Diagnosis and management of ADHD in children, young people and adults (National Clinical Practice Guideline Number 72). National Institute for Health and Clinical Excellence; 2009. http://www.nice.org.uk/nicemedia/live/12061/42060/42060.pdf

SE Sprich,LE Knouse, C Cooper-Vince, J Burbridge, SA Safren. Description and demonstration of CBT for ADHD in adults. Cognitive and Behavioral Practice 2010;17:9-15.

S Moulton Sarkis. 10 simple solutions to adult ADD: How to overcome chronic distraction & accomplish your goals. Oakland, CA: New Harbinger; 2006.

L. Honos-Webb. The gift of adult ADD. How to transform your challenges and build on your strengths. Oakland, CA: New Harbinger; 2008.