A great book on the effectiveness of cognitive-behavioral therapy, or CBT, for people who have ADHD has just been released in paperback. While it is intended for therapists who want to help people with ADHD to build skills in executive functioning, the first half of the book presents evidence about the areas in life where working adults may struggle and fail, in spite of being talented, articulate and hard-working. It's called Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction by Mary V. Solanto. She is a psychiatrist at the Mount Sinai School of Medicine in New York City. I've taken some important definitions and descriptions from this book which hopefully will shed light on behaviors (usually negative) that you may observe in yourself or your children.
“Insufficiency of Medication as a
Comprehensive Treatment for ADHD”
Personally, I am very impressed
with the quality of the writing in this book, both by Solanto and her other
contributors. She provides evidence of the success of using a cognitive-behavioral therapy program, whether
or not the person with ADHD is taking medication or not. She focuses on the
challenges that adults face, those adults who did not “grow out of” ADHD (which
is estimated to be about half of the population who has ADHD as children –
about 8% of the population). I wish there were more programs here in the Los
Angeles area which used this approach. While some mental health facilities
offer classes on CBT (such as Kaiser Permanente), they do not gear it to the
challenges faced by people with ADHD.
Even with medication – which is not
effective for all patients with ADHD – there are skills and behaviors which
were never learned as children that the medication cannot “teach” the person
how to do (pp. 13 – 14). Mainly these are the executive functions or the ability to self-manage: organizing,
planning, self-monitoring, accessing working memory, utilizing self-inhibition,
shifting/ transitioning attention from one task to another, etc. (p. 14). This
lack of executive functions is developmental – many of these skills eventually
do “stick” but usually about 2 – 3 years behind their peers. This delay may be
caused by a physical difference in the brain. “Structural and functional
neuroimaging studies both in adults (Seidman, Valera & Bush, 2004) and in
children (Seidman, Valera & Makris, 2005) have revealed deficits in the
volume and activation of regions of the prefrontal cortex known to subserve
these executive functions” (p. 15).
Some researchers frame this as “a fundamental deficit in inhibitory control”
(Barkley, Murphy & Bush, 2001; Nigg, 2006) – whether it is to stop an
automatic impulse in a given situation, or to “prevent interference from
extraneous stimuli.” Russell Barkley is
a well-known proponent of this description of ADHD: “Inadequate inhibitory
control results in a a proneness to respond to immediate external or internal
stimuli, and is manifested cognitively as poor working memory, distractibility,
failure to carry tasks through to completion, inattention to detail, and
‘careless’ errors. Tasks that are lengthy, multistep, or inherently challenging
will be particularly vulnerable to disruption. Inadequate working memory may result
in difficulties in monitoring and adjusting current behavior so as to maximize
timely progress toward overarching goals” (p. 15).
Another area that medication does
not help someone suffering from ADHD is an insensitivity
to reinforcement. That is, consequences of current behaviors simply don’t
enter their minds. This has been described as having an “elevated reward
threshold in ADHD” (p. 16). Another way of looking at this is having a “steeper
delayed reinforcement gradient” (p. 16). This means that people with ADHD can’t
be satisfied sticking to an unpleasant task with the knowledge that “it will
matter later when you apply to college” or “this could help you get a job
promotion later.”
An unfortunate word is used
medically to describe someone who suffers from two or more disorders
simultaneously: “comorbid.” Some practitioners now use the word “co-occuring”
which makes more sense and is less… morbid. It is quite common for people with
ADHD to develop anxiety or depression,
caused by years of failure and underachievement. “Adults with ADHD complete
fewer years of education, have higher rates of unemployment… and higher rates
of marital separation and divorce. In addition, adults with ADHD have higher
rates of substance and alcohol abuse disorders (18%) as well as increased rates
of anxiety (51%) and depression (32%; Kessler et al., 2006),
and adult women with ADHD are at greater
risk for eating disorders (Biederman et al., 2010). (pp. 8 – 9).
All of these symptoms and outcomes
are probably well-known to you already, as a parent with a child with ADHD.
There is hope, of course, in several types of treatments, starting with
medications that help the neurotransmitters in the brain focus better and
longer. What may not be familiar is a treatment called Cognitive-Behavioral
Therapy, or CBT.
CBT is a treatment that is
psycho-social; that is, it is information that is taught to individuals who
seek to change their behaviors. A person with ADHD may not have that “inner
voice” that warns them to keep their mouths shut during a sensitive
conversation, or to look at a long-term outcome, or to consider at least three
bids before deciding on a contractor. CBT helps people become aware of the
specific types of situations that can get them into trouble, then to identify
what they normally think and do in those situations, and then to think and do
something different – in order to achieve a different (positive) outcome.
CBT is founded on the work of Aaron
Beck, Albert Ellis, and others (p. 20). The program described by Solanto in
this book has key ingredients to help people make changes in their behaviors:
·
Explicit skills training
o
Time management: how to use a planner
o
Time management: how to prioritize activities
o
Organization: how to use the space around you
for your work – placement of tools and other materials needed on a daily basis
·
Development of Compensatory Strategies
o
Setting up a work environment to minimize
distracters
o
Setting a timer to get work done
o
Maximizing important external prompts, like
post-it notes or an electronic calendar
·
Generalizing positive statements/maxims
o
Use of Take-Home Exercise activities that the
person can do by himself
o
Frequent repetition of positive statements so
that they will automatically start popping up in the person’s consciousness
(development of that “inner voice”), such as “Out of sight, out of mind,” and
“Getting started is the hardest part.”
There are many more ideas presented in this book about how
to accomplish this “brain training,” including a complete 12-week training
manual written for therapists to take a group of participants through these
ideas and give them specific and practical tools to change their behaviors.
Hopefully with such a well-written
guide now available in paperback (just published in 2013; I received my copy on
September 12, 2013), we will see more utilization of this healthy therapy, CBT.
Solanto, MV. (2011). Cognitive-Behavioral Therapy for Adult ADHD. New York: Guilford Press.
