Attention-Deficit Hyperactivity Disorder (ADHD) in ADULTS

Shifter factsheet on symptoms, NNE’s, LB’s, and Shift Conceptualization. Includes Case Study, Common Comorbidities,  Best Practices on Pharmaceutical Interventions, Referral Guidelines, and Additional Therapeutic Interventions. 

Symptoms (From DSM)

• Hyperactive/Impulsive
• Inattentive
• Other ADHD-related symptoms
• Rejection Sensitive Dysphoria

Common Non-Nurturing Elements that Contribute

• One or more parents with ADHD. This may show as parent being…
  • Easily overwhelmed or emotionally explosive
  • Easily distracted, unreliable or inconsistent
  • Permissive OR Authoritarian parenting style
  • Instability of parent’s employment or relationships
• Difficulty in school
  • Lack of support or empathy from authority figures in their life
  • Getting into trouble in school (overly talkative, underachievement, boredom, aggression)
• Difficulty with social interaction
  • Bullied OR being the bully
  • socially awkward/anxious

Associated LBs – Not exclusive

• I’m incapable
• I’m cannot succeed
• I’m lazy
• I’m not good enough
• I’m inferior
• There’s something wrong with me
• I’m not in control

Shift Conceptualization

There are two different axes a clinician should be aware of when approaching treatment for ADHD with the Shift Protocol: 1) the primary (or neurobiological) symptoms of ADHD, as outlined in the DSM-5 diagnostic criteria, and the 2) secondary effects of living with ADHD (ie. LBs, DN’s, etc).

As for ADHD specifically, the research is clear that the best treatment for the primary symptoms of ADHD is a combination of medication and behavioural interventions. If the client is interested in seeking medication, a referral should be made to a medical professional, preferably a psychiatrist. Behavioural interventions for ADHD may be done in therapy and should be appropriate to the presenting concern (explored more in the Additionally Beneficial Therapeutic Interventions section).

With respect to secondary effects, it is best to understand that many people with ADHD experience a chronic sense of underachievement, inconsistency, and negative feedback from others (up to 10x as often for some children). This is especially true when a diagnosis comes later in life, ADHD is not adequately treated, or when early-life caregivers do not have an accurate understanding of ADHD symptoms and mechanisms. Inattention or difficulty with motivation may be perceived as laziness or a lack of motivation when in reality the brain is not able to perform the cognitive functions required of it in a particular situation.

Case Study 

A child with ADHD is the class clown, easily bored in class, and doesn’t do their work. These are signs that the child is not adequately engaged with or stimulated by their environment. As the child receives corrective feedback from authority figures in their life, they internalize LBs like “I cannot succeed”, “I’m not good enough,” “I am lazy”, or “I am inferior.” The teacher tells the child “you have so much potential. You just need to apply yourself more.” Worse, the child’s parents may attempt to correct the behaviour with punishment. All the while, the child continues to suffer from the symptoms of ADHD, and not receive the appropriate support, instilling further limiting beliefs such as “There’s something wrong with me”, “I am defective”, or “I am hopeless”

• • If the child manifests hyperactive/impulsive symptoms, this may alienate them from their peers, resulting in the LB “I am unwanted” or “I don’t fit/belong”, the DN “I need to be wanted/fit in”, and an overall level of social anxiety.
  • As the child matures, DN’s solidify, creating high-level anxiety around any performative or achievement-oriented task (eg. I need to succeed, I need to be perfect, I need to prove myself, I need to be in control). The fear may be “I’m going to fail anyway, so why try?” or it may manifest as overly ambitious goals. Most pernicious might be the belief that symptoms of ADHD are actually character flaws (eg. I am lazy), and not symptoms of a neurodevelopmental disorder that can be managed.
  • As an adult, inconsistencies and turbulence in both work and relationships may further exacerbate the LB “I cannot succeed,” resulting in a severe fear of failure and a sense of hopelessness, which may be seen as anxiety or depression. This, in combination with the impulsivity of ADHD, may be seen in adults as a strong tendency to opt-out, either through substance use, thrill-seeking, risky behaviour, job performance issues. People with ADHD often fluctuate wildly between extreme passion for a new goal (“I NEED TO SUCCEED”) and extreme disinterest (OPT OUT: “I CANNOT SUCCEED” or “I AM INCAPABLE”).

It should be noted that individuals with ADHD may present with stronger emotions than the average person. This may be due to emotional impulsivity, which is a form of impulsivity. In layman’s terms, people with ADHD may “have a lot of feelings.” The ultimate goal of Shift Protocol work with ADHD is to remove LBs & DN’s that inhibit a sense of hope and self-efficacy, and open the way to recognizing strengths and weaknesses with a level of acceptance and self-compassion.

Additional Items to Investigate

• Medication
• Work history – unstable?
• Relationship history – unstable? Infidelity? Impulsivity or anger? Unreliable?
• Other issues, primarily anxiety, depression
• Time management/organizational skills
• Finances – impulse spending? Difficulty sticking to a budget?
• Addictions? Substance use, gambling, pornography, video games
• History of injury or risky behaviour? Concussions, extreme sports, etc.
• Strengths – This is critical for the individual to feel a sense of self-worth and accomplishment in their life.

Best Practice Pharmaceutical Interventions

ADHD is generally treated with either stimulant or non-stimulant medication.

Stimulant Medications

• “For adults aged 18 years and older, the NICE guidelines recommend starting with either methylphenidate or the amphetamine formulation, lisdexamfetamine.” (Posner, Polanczyk,& Sonuga-Barke, 2020)
• The most common medications given for ADHD are stimulants, specifically methylphenidate or amphetamine. Methylphenidate blocks presynaptic dopamine and norepinephrine transporters, thereby increasing catecholamine transmission; amphetamine also inhibits both transporters, but additionally increases the presynaptic efflux of dopamine. These have the highest success rate at alleviating primary symptoms of ADHD, although may have undesirable side effects for some individuals

Side effects & Medication Concerns

• Most common side effects include appetite suppression, Insomnia, dry mouth, nausea
• Side effects are often more pronounced in children; medication should be considered for children under 5 only when other possible solutions have been used.

Other Concerns

• There is some validity to the concern that early long-term stimulant medication use may result in a reduction in height later in life, as well as increased weight. However, this may be attenuated by so-called “drug holidays” over holiday periods and summers.
• Concern about stimulants leading to increased risk of substance abuse is NOT supported by research. In fact, longitudinal research has suggested that stimulant use has no effect on, or can even lower, substance abuse risk.
• Concern that stimulant use may result in an increased risk of cardiovascular events is not supported by research.

Non-Stimulant Medications

• “Relative to stimulants, non-stimulant medications have lower responses and effect sizes and thus are typically reserved for patients who respond poorly or have intolerable side-effects to trials of stimulant formulations.”  (Posner, Polanczyk,& Sonuga-Barke, 2020)

It should be noted that “Pills don’t teach skills.” In other words, medication may help alleviate some of the primary, in-the-moment difficulties with ADHD. However, living with ADHD may have prevented an individual from learning skills that are needed to succeed in their life. For example, once being prescribed medication, an individual may be able to focus long enough to schedule out their week. However, this doesn’t mean they’re going to know how to do that, and if they have unaddressed LBs (eg. “I cannot succeed”), they may still avoid the task. Even after pharmacological treatment has started, they still may need to learn skills, as well as address their LBs, before true success can be met.

Common Comorbidities

• Major depression
• Dysthymia
• Bipolar disorder
• Generalized anxiety disorder
• PTSD
• Panic disorder
• Addictions, including substance use and problem gambling

Referral Required or Recommended

• Consult with the family doctor for a referral to a psychiatrist if diagnosis or medication are desired; this is particularly important if differential diagnosis is required

Additionally Beneficial Therapeutic Interventions

• Life Analysis, particularly for satisfiers, sleep, exercise, & social
• Time management & scheduling techniques (eg. bullet journaling, to-do lists)
  • The key to success is two-fold:
    • Finding a system that works. If there are strategies that already work, keep using them.
    • Consistency in using the strategy. If you tend to forget, set digital reminders and set time aside to check-in.
• Energy Matching
  • Determining when the client’s “high energy” times of the day are, and planning on doing more demanding activities during those times
  • Conversely, planning to do easier tasks during low energy activities

References

Posner, J., Polanczyk, G. V., & Sonuga-Barke, E. (2020). Attention-deficit hyperactivity disorder. Lancet, 395, 450-462.