Attention deficit hyperactivity disorder (ADHD) was until recently thought to be a condition of childhood which remitted before adulthood. Characterised by difficulties sustaining attention, overactivity and problems with impulse control, the condition affects around five per cent of children. There is now an established body of research showing that in at least half of ADHD cases, symptoms continue to pose clinically significant difficulties into adulthood. The DSM-5, released in 2013, now provides adult-specific criteria, including a reduced symptom count for adults compared with children (five rather than six symptoms in each criteria) (American Psychiatric Association, 2013). ADHD can be summarised according to three presentations in both children and adults:
1. ADHD-combined type (ADHD-C) meeting symptom count for both inattention and hyperactivity-impulsive criteria.
2. ADHD predominantly inattentive type (ADHD-I) meeting inattention symptom criteria but not hyperactive-impulsive.
3. ADHD predominantly hyperactive type (ADHD-H) meeting hyperactive-impulsive symptom criteria but not inattentive.
To meet diagnostic criteria, several symptoms need to have been present before 12 years of age, symptoms need to occur in more than two settings and reduce the quality of social, academic or occupational functioning. Adult ADHD symptoms impact on everyday life and result in difficulties with inhibition, poor time management and organisational ability, difficulties engaging in problem-solving over time, low self-motivation and poor self-regulation of emotion.
Numerous psychosocial problems have been associated with having ADHD into adulthood. Academic difficulties frequently present in childhood and adolescence transcend into later employment difficulties including lower job status, frequently changing jobs, co-worker relationship difficulties, quitting and losing jobs, and more unexplained days off work (Secnik, Swensen & Lage, 2005). Difficulties with emotion regulation can manifest in adulthood as relationship and interpersonal difficulties, poor frustration tolerance and anger dysregulation. ADHD can also have a significant impact on self-esteem with difficulties completing tasks throughout one’s life producing an entrenched negative self-view. Around three quarters of adults with ADHD will have at least one comorbid psychiatric condition, such as substance abuse, mood, anxiety and learning disorders (Faraone & Biederman, 1998; Simon, Czobor, Balint, Meszaros, & Bitter, 2009).
Multidisciplinary management
Studies in adult ADHD have shown that best outcomes derive from an integrated, multimodal treatment approach (CADDRA, 2010; Kooij et al., 2010; NICE, 2016). The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Adult ADHD practice guidelines (2012) consider the National Institute for Health and Care Excellence and the Canadian ADHD Resource Alliance guidelines as the most appropriate for use by Australian psychiatrists for the treatment of adult ADHD (RANCZP, 2012). The Australian Psychological Society (2016) has EQIP guidelines for ADHD for psychologists. There are currently National Health and Medical Research Council1(NHMRC) ADHD guidelines for the management of children and adolescents but not adults (NHMRC, 2012). Treatment must include a comprehensive assessment using DSM-5 criteria and development of an individualised management plan.
A multimodal approach from a multidisciplinary team may include medication, psychosocial management strategies and, where appropriate, vocational and educational interventions. Medical conditions (e.g., hearing, vision impairment) should be considered prior to confirmation of diagnosis. Medical treatment may be undertaken by a psychiatrist, or delegated to a general practitioner, with annual/biannual psychiatrist review, as per local health department stimulant prescribing legislated requirements. Counselling, strategy training and where required, liaison with external parties, may be undertaken by the medical practitioner, or following referral to a psychologist. Additionally, there are various organisational and assistive technologies which can be helpful (CADDRA, 2010).
Medical management
As part of the treatment plan, clients should have their ADHD symptoms and impairment monitored, including aggravation or emergence of psychiatric comorbidity, along with documenting ADHD rating scale scores and mental state examination. Where there is comorbidity, the comorbid condition may need to first be stabilised prior to commencing treatment for ADHD.
Drug treatment is the first-line treatment for adults with ADHD with either moderate or severe levels of impairment (CADDRA, 2010; NICE, 2016). There are currently three main classes of medications available and approved in Australia to treat ADHD in adults: stimulants (dexamphetamine and methylphenidate), and non-stimulants (atomoxetine and clonidine).
Stimulants are the first-line choice for ADHD, demonstrating an effectiveness as high as 70 per cent in symptom improvement (Fredriksen, Halmøy, Faraone, & Haavik, 2013). Methylphenidate and dexamphetamine are both available in short-acting and slow-release formulations. The slow-release formulations have a slower onset of action, but a smoother course and fewer rebound symptoms as the dose wears off. Side effects include dry mouth, thirst, tachycardia, insomnia, headache, migraine, loss of appetite, anxiety, psychosis, mania and the potential for abuse and diversion. Stimulants are relatively contraindicated in patients with active substance abuse, psychosis and tic disorder.
Psychological management
Although medications may provide improvement in some core symptoms, the effects may not translate to functional improvement, such as improvement in time management, self-esteem, planning and organising. Psychosocial treatments have been employed to help address the symptoms and poor functional outcomes of adult ADHD. Research on the efficacy of psychosocial treatments for adults with ADHD is increasing but is behind that for children/adolescents with few randomised controlled trials in adults and cognitive behavioural therapy (CBT) the most researched approach (Mangia & Hechtman, 2012). Both group and individual psychotherapy have been employed across a range of therapy approaches to meet the complex needs of clients with ADHD.
Best practice guidelines for the management of adult ADHD indicate the following types of psychosocial therapies be considered (NICE, 2016).
- Psychoeducation is an important part of treatment to provide the client with knowledge about ADHD, the associated problems and functional impairments as well as information about managing the core difficulties, such as organisational skills, and associated difficulties, such as sleep management.
- Behaviour self-management strategies can be used for goal setting with appropriate contingencies to address organisational problems and the client’s goals relating to areas such as diet, sleep and exercise.
- Social difficulties which may stem from ADHD symptoms including being overly talkative, interrupting and intruding on others and being restless/impulsive can be addressed through education and social skills training. For adults with ADHD with more severe and persistent social problems, consideration of a possible autism spectrum disorder may be warranted. Anger management including conflict resolution skills and relaxation training may also be necessary.
- Psychotherapy, using traditional approaches such as CBT, can be used to address associated difficulties such as low self-esteem, depression, anxiety and substance abuse problems.
- Vocational interventions may be necessary and psychologists may be called upon to develop workplace accommodations for clients, for example, ensuring the work environment is quiet with minimal distractions.
- Family therapy may be required given ADHD is highly heritable and the symptoms of ADHD may result in negative interactions between parents and children. Adults with ADHD who have children with ADHD should consider best practice parent training programs (NHMRC, 2012). Couples therapy may also be required.
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Treatment challenges
Specialist ADHD care may be difficult to find locally or be unaffordable due to the absence of publicly funded treatment centres, lack of ADHD experienced clinicians, and educational barriers may further complicate treatment. Financial strain caused by low income, impulse spending, or self-medication with non-prescribed substances, can impact on treatment affordability. Disorganisation and lateness, and resistance to homework because of past negative experiences, can also lead to suboptimal care with avoidance or premature cessation of medication and psychological therapies. These challenges may be reduced through collaborative multidisciplinary care with the client, carers and multidisciplinary team actively involved in the establishment and regular review of a personalised treatment plan.
Conclusion
There is growing recognition and acceptance of adult ADHD and practice guidelines emerging to support psychologists in managing these clients. A multimodal approach from a multidisciplinary team is needed to address the diverse range of difficulties frequently present. While drug treatment is the first line treatment approach for those with moderate to severe difficulties, psychosocial interventions are an important treatment component which can help reduce the poor social, health, academic and occupational outcomes associated with adult ADHD.
Useful management resources for psychologists and their adult clients with ADHD
For psychologists
Symptom rating scale
- Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist: https://add.org/wp-content/uploads/2015/03/adhd-questionnaire-ASRS111.pdf
Example treatment manual
- Young, S., & Brahman, J. (2012). Cognitive-Behavioural Therapy for ADHD in Adolescents and Adults: A Psychological Guide to Practice. (2nd Ed), Wiley-Blackwell
Websites
For clients
Books
Barkley, R. (2010). Taking charge of adult ADHD, Guilford Publications
Information sheets
The first author can be contacted at [email protected]