Psychotherapy for ADHD

Psychotherapy for ADHD

If you've met one person with ADHD, you've met one person with ADHD.

What Does ADHD Look Like?

Attention deficit hyperactivity disorder (ADHD) is a complex disorder having multiple causes including genetics as impacted by one’s environment. The condition is usually diagnosed in childhood, when difficulties arise during play and school, and it is marked by lack of concentration, short attention span, and physical restlessness. ADHD often is blamed on bad parenting, or a “bad” attitude. However, brain-imaging studies have shown that children with this disorder have an underlying neurological dysfunction, which likely accounts for their behavior. In the simplest terms, the brains of these children have yet to come fully “on-line.” It is conjectured that while certain important brain pathways are working normally, cortical regions involved in attention, impulse control, and stimulus integration abilities, have yet to become fully active. ADHD is a widespread affliction that we are just beginning to understand. People with ADHD suffer from overload. That is, they have heightened awareness of incoming stimuli, particularly sight, sound, and touch. They are so bombarded by the normal stimuli in their environment that they cannot filter out the background noise, and they have trouble focusing or concentrating on a problem or a task. Because of their inability to focus, those with ADHD have trouble completing what they start. They have difficulties with making plans and even more difficulty in carrying out plans in an orderly fashion.

People with ADHD tend to be disorganized. Children have messy rooms; adults have cluttered desks; daily activities tend to be chaotic. Attics and basements are likely to be filled with partly completed sewing projects, woodworking projects, repairs, and notebooks; desk drawers are likely to be cluttered with unfinished letters, outlines, and project plans. Many people with the disorder are highly intelligent, but they tend to be underachievers because they cannot concentrate or sustain interest. As a result, family, friends, teachers, and coworkers become impatient and expect them to fail. People with ADHD also have trouble adapting to change. Their life is so full of tumult that even a minor additional change in their routine can be upsetting or can even create a crisis, eg, a parent goes away on a trip, a new teacher takes over a class, the family moves to a new city, or a pet dies.

ADHD afflicted people live under stress so severe they cannot tolerate frustration, and when they are frustrated, they are likely to become angry. The anger tends to come suddenly and explosively, accompanied by slamming doors, harsh words, tantrums, and leaving important meetings in a frenzy. Children get into fights; adults lose jobs and alienate friends. Afterwards, they may be sorry, but the damage is done. With their high level of frustration, people with ADHD are impatient. They hate to wait in line, and delays of any kind can make them frantic. Whatever is going on – a trip, a movie, a class, a discussion – they want it to go quickly and be finished. Their impatience makes people with ADHD impulsive. As children, they leap into action without thinking of consequences. As adults, they drive too fast, use power tools carelessly, and plunge into activities without thinking of the danger. The result is they often hurt themselves or others. People with ADHD have trouble with their orientation to time and space. They may have trouble differentiating their right hand from their left; they may have difficulty following a set of instructions, reading a map, or telling time. As babies or children they constantly are on the move, squirming, twisting, and getting into everything. As adults, they are restless, easily bored, rebellious when asked to follow a routine, and always on the move. It is noteworthy that some of these characteristics are tied to comorbid Oppositional Defiant Disorder (ODD) and conduct disorder (CD), separate from ADHD per se.

Brief History of ADHD:

ADHD was first ambiguously described in 1775 as a disorder of attention by German physician Melchior Adam Weikard. A more refined description was later written by Scottish physician Sir Alexander Crichton in 1798. However, unfortunately due to the description by British pediatrician Sir George Frederic Still in 1902 as a moral defect, ADHD has been a very controversial subject and continues to be. It was only until the late 1960s that the term “hyperkinetic reaction of childhood” was used in the DSM-II, and ADHD has only been given full recognition in mainstream society since the mid-1990’s.

Mechanics of the Human Brain:

The human brain consists of roughly 100 billion neurons.  Each neuron sends information to other cells via an axon, which can range anywhere between 1 mm long up to over a meter long.  Neurons also have tens of thousands of dendrites which are pathways by which neurons receive information.  The point at which neurons make contact is called a synapses.  Connections in the brain may either function as a braking system or accelerate certain communications between these neurons.  The processing capacity within these pathways are extensive.  A piece of brain the size of a grain of sand is said to contain 100,000 neurons, 2 million axons, and 1 billion synapses communicating with one another.  The management of this communication between the neurons is accomplished by neurotransmitter chemicals, which are stored in vesicles at the back end of each neuron.  Neurotransmitters are released to rapidly fire the messages across the synapses.  When the required amount of neurotransmitter fires and reaches the targeted receptor, it is then fired over to the next receptor and the process is repeated, as long as there is sufficient neurotransmitter to keep the communication going.  During this process, any unused neurotransmitter is recycled through the axon through transporters, and the system can then be reloaded.  This process is extremely fast: transmitters stay on each receptor for only 50 milliseconds; so in one millisecond, 12 messages potentially could be carried across a synapses.

The ADHD Brain:

It is a myth that ADHD is a disorder in which the brain is overactive, and therefore, Attention Deficit Hyperactivity Disorder is essentially a misnomer.  In reality, the ADHD brain is a neurodevelopmental disorder in which the neurotransmitters dopamine and norepinephrine are underactive, primarily in the prefrontal cortex.  They are either firing at inappropriate times or are not being received by the receptor meant to “catch” it.  The underactivity of these neurotransmitters cause impairment in executive functioning.  Executive functions are cognitive skills required to control the behaviors and steps necessary to attain a goal.  Whether this is simply waking up in the morning and brushing your teeth, to putting together papers for a project, cleaning out your garage, or even losing 15 pounds, executive function skills are necessary to make this happen.

Executive function skills include prioritization, organization, sequencing, sustained attention, filtering out competing distractions, time management, planning, motivation, initiation, self-monitoring, and working memory. They start developing in the human brain during the first 6-12 months of life. However, because of the complexity of executive function skills, they continue to develop in stages well into adulthood. Due to the increasing demands in the world of academia, by the time we have reached adolescence, we require a significantly developed range of executive function skills in order to effectively execute and perform tasks and solve problems. From activities as simple as getting up in the morning or remembering to take a homework assignment to school, to the complexity of regulating behavior in the face of temptations and distraction that will arise from the presence of peers, executive function skills are imperative to our success.

In children, preteens, teens, and young adults with ADHD, the development of executive function skills are often delayed by up to 1/3 of their age and at least 2-3 years behind their true age until the Prefrontal Cortex (PFC) is fully developed by around age 25. In other words, a 13-year old with ADHD could exhibit all the hormonal changes a teenager typically goes through physically, and at the same time have the organization, time-management, and impulse control skills of a nine or ten year old. For instance, the biological circadian rhythm, or “wake-sleep clock” in the adolescent body changes so that they don’t become sleepy until somewhere between midnight and 2:00 AM, and therefore wake later because they still need a good night’s sleep. Add to the mix the fact that school requires students to start classes anywhere between 7:30 AM and 8:30 AM, depending on the region of the US. With the addition of juggling extra-curricular activities, homework, due dates, and socializing, one gets a sense of the reasons most teens are frequently tired. In short, even teens with good executive function skills will struggle sometimes. For those who live with ADHD, the difference is that the executive function deficits they experience are evident in childhood well before adolescence and cause significantly more impairment in daily activities, emotional regulation, social skills, and relationships across at least 2 domains. Because it is usually around middle school when the level of homework and expectations become heavier than in the earlier grades, this is the time when it is the easiest to see how weakened executive functions skills can cause obstacles for the individual with ADHD. That said, preteens and teens with ADHD too often are missing the help and assistance they need, perhaps because there is such an ambiguous line between weakened executive function skills in teens without ADHD and teens with ADHD.

While ADHD is often noticeable and diagnosed in childhood or adolescence, it can and does affect individuals well into adulthood.  Symptoms of ADHD can affect couples and the communication and interaction patterns within relationships.  Symptoms of ADHD are often perceived as intentional and can frustrate partners and other family members who feel confused as to why behaviors seem to remain unchanged despite efforts.  Likewise, symptoms of ADHD can also affect friendships and other peer interactions, not just in childhood and adolescence, but also in adulthood.  Many adults with ADHD have struggled with symptoms since childhood but were not diagnosed until adulthood, thereby impacting their frustrations and challenges with the disorder even more. Those with ADHD often find themselves apologizing to people for not returning phone calls, emails, forgetting scheduled events, experiencing disorganization and trouble planning things out. They may miss deadlines at work or have trouble following through on projects or plans.  They may also struggle to follow through on familial responsibilities, especially ADHD parents with children who need help getting ready for school and establishing routines on a daily basis.  Many adults who experienced external hyperactivity as a child now experience internal hyperactivity in the form of anxiety, overthinking, ruminating about things throughout the day, or having trouble “shutting their brain down” at night.  More importantly, no matter which stage of life one is in, whether it be childhood or adulthood, many people with ADHD do not feel understood by others and experience a grave sense of failure and desperation as a result of ADHD being seen as a moral defect.

ADHD Presentation Types:

As aforementioned, it is important to understand that ADHD is not a disorder of character or morals.  Therefore, it is not a problem of willpower, or lack thereof, nor a matter of selfishness, irresponsibility, laziness, incompetence, or spite; but rather a chemical problem in the synapses pathways of the brain.  That said, it is not an intelligence problem, either, and in fact, people who have ADHD are usually well above average in intelligence, and this is one reason why ADHD is overlooked and contributes to the under-diagnosis of the disorder.

Sometimes, a person with ADHD will present with executive function deficits as symptoms such as skipping over details and making careless mistakes causing inaccuracies in a project or work, difficulty in sustaining attention in tasks, mind seems to be elsewhere causing difficulty in listening when spoken to directly, having trouble following through on a task, having trouble initiating a task, difficulty organizing tasks, whether it be putting steps in order or keeping materials for the task in order, to being messy and disorganized or having poor time management and estimating how long a step or task might take, thereby not meeting deadlines, avoidant or reluctant to engage in tasks, especially when not interesting, losing personal items or things required to complete a task, easily distracted by external stimuli, or forgetful in daily activities.  These symptoms are indicative of the Predominantly Inattentive Type.

Some people with ADHD will present with executive function deficits as symptoms such as fidgeting, tapping hands or feet, or squirming in the seat, leaves seat at school or work when it is expected to remain seated, runs about or climbs on things (or if an adult, seems restless), unable to engage in activities quietly, often described as “on the go”, excessive talking, blurting out answers or ideas before thoughts or other people’s questions are completed, difficulty waiting one’s turn, impatience, interrupts, or intrudes on others.  These symptoms are indicative of the Predominantly Hyperactive/Impulsive Type. 

In cases when the person has symptoms from both categories, this is indicative of the Combined Type.

In any of the 3 types, a person needs to have at least 6 or more of these (5 if an adult) which has lasted for more than 6 months, symptoms present before age 12, and causes significant impairment in at least 2 domains, such as work and social arenas, or home and school.

ADHD Psychotherapy/Coaching:

As mentioned above, there is sometimes confusion surrounding the nature of these symptoms.  I often hear people respond to the symptoms of ADHD with skepticism, “Don’t all of us exhibit these symptoms from time to time?”  Or, “Isn’t it true for everyone?  Anyone is going to pay attention to something if it’s interesting more than if it’s not.”  And these are valid wonderings.  The difference for those with ADHD is that these symptoms are not “from time to time”, despite ADHD being an inconsistent disorder.  ADHD isn’t fleeting, and because of this the ramifications cause impairment and a decrease in the quality of their life whether it be at home, work, school, or in relationships.  Additionally, it is true that people will pay attention more to things that are interesting, but when things are not interesting people generally are able to push through when they know they have to do it.  Those with ADHD, on the other hand, do not have enough dopamine to push through certain tasks, unless the consequences of not pushing through are perilous and therefore increase the dopamine level.

It is important to note that this does not mean one with weakened executive function skills is not capable of reaching goals nor eligible for therapy. On the contrary, ADHD therapy is a tailored collaborative partnership by which individuals are empowered to develop the awareness, cognitive processes, behavioral patterns, and environmental structures to overcome the performance deficits caused by weakened executive skills. My approach involves emphasis on educating the patient about ADHD in general, as well as developing a strong knowledge of one’s own ADHD unique to him/herself. Strategies and actions are then designed to strengthen specific executive function skills, and progress is monitored by creating accountability in concert with goals. Interaction patterns within relationships can also be a focus in ADHD therapy, especially in helping other family members understand the nuances of ADHD and facilitating stronger relationships within the family and with peers.

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