Download Document

Here, There and
Everywhere: Adult ADD
Hal Wallbridge, Ph.D., C.Psych.
Julie Beaulac, Ph.D., C.Psych.
Session Objectives
1.
2.
3.
4.
Provide an overview of the challenge in
accurately diagnosing ADD in adults
How a diagnosis of Adult ADD is made
Tips for managing patients with attention
problems
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, selfdoubts
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.
2.

Try not to get too hung up on a getting a
diagnosis: “You might have ADD, it is difficult to
be sure”
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. easygoing/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.