Treatment of Adult ADHD
By Heidi Bernhardt, RN
Treatment for Adult ADHD Should Be Multifaceted (multimodal).
- Education about ADHD for the adult with ADHD as well as their families
- Review and analysis of how symptoms impact the particular individual
- Discussion and implementation of individualized appropriate coping strategies
- Implement required home and workplace accommodations to offset impairments
- Follow-up care to reassess coping strategies and accommodations that have been put in place and to discuss potential treatment options, with a psychologist or other therapist (CBT, mindfulness, therapy) ADHD coach (ADHD coaching ) and/or physician (medication).
Educate Yourself and Your Family
Educating yourself about what ADHD is and more importantly how it impacts you as an individual is the most important first step in the treatment process. ADHD can substantially impact almost all aspects of your life: work, home, relationships, finances and mental and physical health. Although generalized symptoms help us to diagnose the disorder, exactly how these symptoms impact the individual depends on many factors: type, severity, other personality traits, other coexisting disorders and learned healthy or unhealthy strategies. Educating your family about ADHD can be one of the most beneficial steps in repairing past emotional rifts caused by ADHD behaviours. Understanding that forgetfulness or impulsivity is not due to lack of caring, but rather caused by a disorder can significantly help to heal some of the hurt and confusion. However, this knowledge must be followed up by openness to change and the implementation of strategies and treatment. ADHD is not a life-long pass for bad behaviour, but rather the knowledge of ADHD can lead to less impairment and improved behaviour leading to a life of happiness and success.
Exercise produces several hormones that can benefit brain functioning and can impact learning.
Cognitive Behaviour Therapy is a form of therapy that focuses on dysfunctional emotions, maladaptive behaviours and cognitive processes that are impairing to daily functioning.
ADHD Coaching can assist with identifying areas of difficulty, assist with strategies and provide accountability and support.
Mindfulness can assist with better awareness of attention, manage stress, be less reactive top impulsive thoughts and be less judgemental of ADHD symptoms.
Relationship and Family Difficulties
Medication may be considered as part of the treatment plan in combination with strategies and accommodations. Medication treatment may be a useful aid to psychosocial treatments. Medication should never be considered a standalone treatment especially before education of the disorder occurs. Medication can be extremely helpful to many adults with ADHD, especially with attention regulation however medication will not magically make all ADHD symptoms disappear. Adults should expect to have an in-depth discussion with their physician about medication treatment, which symptoms are expected to decrease and which may not. Potential side effects should be discussed in detail before beginning medication treatment. The benefits and risks of any treatment, medication or psychosocial as well as the benefits and risks of not treating the disorder, need to be discussed with healthcare providers for an informed decision can be made.
- Types of medication available for ADHD treatment
- Time-released medication vs. short-acting medication
- Non-stimulant medication
- Medication treatment is introduced with a drug trial
In uncomplicated cases of ADHD medication management is fairly straight forward and typically very effective with minimal side effects. The type of medication that is most often used to manage ADHD is stimulant medication. In the past there were two short or intermediary acting compounds of stimulant medication: Methylphenidate and Dextroamphetamine. Stimulant medications are controlled substances and are therefore strictly regulated; however, they have been around for more than seventy years, and thousands of published research papers are available detailing their safety and effectiveness.
In the last ten years, the development of time released medications that need to be taken only once-a-day have significantly improved the choice in ADHD medications. A time-released medication helps prevent medication levels from fluctuating or causing peaks and valleys during the day. They are usually effective over the work or school day and into the early evening. Once the correct medication and dosage is in the blood stream generally some symptom control is immediate. Some adults do metabolize these medications more quickly than others and may not have coverage for as many hours. These medications are generally in a form that is more difficult to abuse. There are two Methylphenidate-based time-released medications available in Canada at this time, Biphentin, and Concerta, as well as a generic version of Concerta, (additional information about generic medication can be found on this website). The Dextro-amphetamine-based medications available are Adderall XR (mixed amphetamine salts) and Vyvanse (lisdexamfetamine dimesylate).
There is also a non-stimulant medication available in Canada. It is classified as a noradrenalin reuptake inhibitor. This medication’s ingredient is Atomoxetine Hydrochloride and the trade name is Strattera. This medication is required to be taken for 6 to 8 weeks before maximum effectiveness can be reached. This medication may be your doctor’s choice of treatment if you experience problems with anxiety, or tic disorders.
With a choice of once-a-day medications and shorter acting medications adults can now choose the medication best suited to their schedule and needs. Adults who have difficulty remembering to take their medication or need to focus and concentrate for extended periods of the day may find once-a-day medications preferable; however, some adults who may only require the effect for brief periods of time may prefer short-acting medications. If an adult feels they require medication only at those times that they are doing highly focused desk work, they have the choice of taking a medication that stays in their system only three to four hours.
The first medication that you try may not always be the best one for you. Physicians generally start with a low dosage and increase it gradually (start low and go slow) so it may take some time to discover if the first medication tried works for you. Fortunately, 80 percent of people respond to the first type of stimulant medication tried; and of the 20 percent who do not, 80 percent of those respond to the other type of stimulant medication. Side effects may also be an issue with one type of medication and not the other type of stimulant medication. This trial and error approach does not mean that your doctor is inexperienced. Individuals react differently to medications. Although this question is currently being researched, at this time we do not know which medication will always work best for a certain subtype of ADHD or for any particular individual, without actually doing a drug trial.
Information on Alternative Treatment/Therapies
Canadian Pediatric Society’s Psychosocial Paediatrics Committee article that you can access by clicking here.
Challenges to ADHD Treatment
At this time, our biggest challenge in the treatment of adult ADHD is finding physicians who are qualified, able (due to wait lists) and willing to take on new ADHD patients. Until recently, ADHD was considered a childhood disorder and it was believed that children outgrew ADHD in their adolescence. We now know that at least 60 percent of adults maintain at least one of the core symptoms, resulting in some impairment. Most children in Canada with ADHD are treated by pediatricians, which causes a problem in the continuing care of these children when they grow into adolescence and adulthood. Due to this shortage some paediatricians may be forced to treat their patients’ parents since treating a parent with ADHD can be of considerable benefit to the child. Surprisingly there are adult psychiatrists who still believe that ADHD does not exist into adulthood despite decades of research that clearly shows otherwise. If you encounter a physician who does not belief in the existence of adult ADHD, find another physician.
Due to the lack of psychiatrists who deal with ADHD, it has fallen on family doctors to do much of the follow-up care for adult ADHD. Family doctors are slowly becoming more comfortable with prescribing medication for ADHD as follow-up care; however they have little expertise or time to do assessments, education or counselling for patients with adult ADHD. Some psychologists and some other health care professionals, such as social workers, coaches and therapists may be trained and experienced in counselling for ADHD; however these professionals are not covered by provincial health care plans and can be very expensive. Most private health care plans cover up to $500.00 a year per patient for psychological visits.
One of the most important steps in a treatment regimen for ADHD is to educate oneself. A great deal of educational material can be found on CADDAC’s website, in our members-only quarterly newsletter, and in our “Adult ADHD Information Package”.
Lists of educational materials from reputable sources can also be found on the web site. Books are available that can provide insight into how ADHD affects daily functioning. They also supply information on strategies to combat executive functioning impairment. Reading about others’ experiences with ADHD can provide further insight and provide ideas for strategies that can work for dealing with your ADHD symptoms on a daily basis.
Since 4 of every 5 adults with ADHD also have a comorbid, or coexisting disorder that accompanies their ADHD, having a very thorough assessment is essential. Treating ADHD alone is not sufficient if another disorder, such as anxiety, depression, substance abuse, Bipolar Disorder (among others) is also present. A thorough history and evaluation performed during the assessment process should screen for these conditions.