Here, There and Everywhere: Adult ADD

1. Here, There and Everywhere: Adult ADD Hal Wallbridge, Ph.D., C.Psych. Julie Beaulac, Ph.D., C.Psych.

2. Session Objectives • Provide an overview of the challenge in accurately diagnosing ADD in adults • How a diagnosis of Adult ADD is made • Tips for managing patients with attention problems • Non-pharmacological treatment strategies for Adult ADD and attention difficulties more generally

3. Adult ADD Referrals • Many patients are referred for assessment of ADD (56 referrals on waitlist: 40% question ADD) • Level of disability associated with these patients is generally light, relative to other mental health issues • ADD symptoms are difficult to distinguish from common personality traits, therefore, the diagnosis of adult ADD is very hard to make (to both confirm or to rule out)

4. ADD: Quick Review • Maladaptively high levels of impulsivity, hyperactivity and inattention • ADD was originally identified as a neurodevelopmental disorder in childhood; later extended to adults • In adults, the inattention component is seen as more prominent • Adults complain of disorganization, lack of sustained effort and failure to accomplish goals

5. ADD: Quick Review • Prevalence in children is around 5% of the population (rate depends on severity) • Rate in adults has been estimated to be about two thirds of the child rate (3%-4%) • Etiology is uncertain: there is evidence for genetic, environmental, and psychosocial factors

6. Associated Issues • Educational and occupational difficulties • Increased substance abuse • Criminal behaviour • Mental health conditions: mood disorders, anxiety disorders, personality disorders

7. Key Aspects of Diagnosis • The presence of the core problems of inattention, hyperactivity and impulsivity • Long duration of symptoms beginning in childhood • Pervasive impact leading to below normal adjustment • Symptoms not explained by some other condition (what about comorbidity?)

8. Assessment • Clinical interview • Rating scales* (e.g., Brown Attention Deficit Disorder Scale; Brown, 2001) • Psychological testing • Cognitive/attention • Psychoeducational • Diagnostic** * We rarely use these ** Rarely recommended, but we routinely use

9. Case Example • 29 yr-old single female, university student • c/o procrastination, trouble focussing, disorganization, which she mainly attributed to depression • “My problem is not being able to accomplish what I want to do no matter how hard I try or how driven I am to do so” • High grades as a child, but now failing school; can’t read her text books • Tends to quit jobs because bored • 2 suicide attempts in past, chronic back pain • Involved in competitive sports, supportive family, no drugs/alcohol, but 50-100 mg caffeine/day to help concentration

10. Case Example: Testing Results • WAIS-IV: average to high average • CPT-II: “non-clinical” confidence index, but evidence of impulsivity • CVLT-II: good performance • REY: some impulsivity • PAI: thinking problems, negative thoughts, health worries, relational problems, self-doubts

11. Case Example: Outcome • History and testing “support a diagnosis of attention deficit disorder” • Prescribed Ritalin by psychiatrist with good response for attention symptoms: improved grades • She continues to struggle with back pain due to a degenerative condition, with treatment by opiates • She continues to struggle with negative thinking and doubts about her career path • Requested extensive documentation to obtain accommodations to write MCAT, which I denied her

12. Diagnostic Challenges • ADD is very difficult to diagnose • Range of symptoms is more restricted (trait-like) • There is no distinct profile on testing • Many non-ADD patients do poorly on attention testing • ADD patients might do well on attention testing • Expectancy effects on self-report and treatment efficacy are large • The symptoms are over determined • Unlike many mental health conditions, you can’t really tell if someone has ADD by interacting with them in a clinical setting

13. What we say to patients Themes: • Try not to get too hung up on a getting a diagnosis: “You might have ADD, it is difficult to be sure” • We suggest that you consider your problems and frustrations as more multidetermined. • The overall goal is to try to encourage the patient to adopt a less simplistic and restrictive way of explaining their difficulties

14. Observations from Years of Cases • We are rarely, if ever, sure about the diagnosis • The biggest predictor of a tentative ADD diagnosis is the patient thinking they have it • We are very unlikely to link ADD alone with significant disability (with exception of academic difficulties) • We still don’t really know the difference between ADD and personality traits

15. ADD and Personality • The Big 5 • Broad-based factor-analytic model of personality structure; very popular in psychology • Neuroticism – (sensitive/nervous vs. secure/confident) • Extraversion – (outgoing/energetic vs. solitary/reserved) • Openness to experience – (inventive/curious vs. consistent/cautious) • Agreeableness – (friendly/compassionate vs. cold/unkind) • Conscientiousness – (efficient/organized vs. easy-going/careless)

16. Conscientiousness • High Conscientiousness: Self-discipline, carefulness, thoroughness, organization, deliberation, better impulse control, need for achievement, orderly, industrious • Low Conscientiousness: Procrastination, impulsivity, lower success at school and work, more substance abuse, more antisocial behaviour

17. Conscientiousness and ADD • Are the characteristic features of ADD the result of a neurodevelopmental brain disorder originating in childhood or simply the result of the person being at on one end of a personality dimension found in the normal population? • Of course, some could argue that conscientiousness emerged in Big 5 research because of the prevalence of ADD in the normal population.

18. Managing Patients with Attention Problems

19. Co-existing Conditions • Assess for co-existing conditions (e.g., substance use, depression, anxiety, relationship/work stress) • Some Questions to Ask: • Age on onset of attention difficulties? • Times when attention difficulties have been better? Worse? • What is the impact of attention difficulties at work? Home? With family/friends? (Assessing for at least moderate impairment across 2+ areas) • How’s your mood? • Are you a worrier? • How is work? Do you enjoy it? • How are your relationships? • What substances are you using?

20. Co-existing Conditions • Manage co-existing conditions • Discuss diagnostic challenge with patients • Discuss options for assessment (public vs. private practice)

21. Treatment Options • Encourage immediate treatment of attention and co-morbid conditions • Self-management • Community-based resources (e.g., self-help organizations, counselling) • Medication • CBT (most evidence, including for many co-existing conditions); mindfulness-based approaches also likely useful

22. Non-Pharmacological Treatment Strategies

23. Psychological Self-Help Workbook for Adults with Attention Problems • Pre-assessment • Section 1: Reflection and life examination • Section 2: Goal Setting • Section 3: Organization and Planning Skills • Section 4: Reducing Distractibility • Section 5: Problem-Solving • Section 6: Practice the Skill of Focusing • Section 7: Become More Present and “World Aware” • Section 8: Balance Your Emotions • Section 9: Interpersonal Issues • Section 10: Living Well • Post-assessment

24. Life Reflection • Values Assessment • Thinking about the different areas of life (e.g., relationships, work, health, leisure), are there areas in your life that you feel are not in line with your values? • How would you like to be in your different relationships? • What type of work you would like to do?

25. Goal Setting • Make goals specific and concrete • Make goals important • Set realistic goals; start small and gradually increase • Schedule goals, write them down, share with others • Review goals often

26. Problem-Solving • Identify the problem • Brainstorm and list a variety of possible solutions • List the pros and cons of possible solutions • Choose the best option and make a plan for how you will put it into action. • Consistently apply that strategy for a period of time to see if it is helpful. • If the first strategy is not helpful, consistently apply the second possible solution for a period of time to see if it is helpful. Continue these steps until you find a solution that can be most helpful to you • Reward yourself when you complete a task.

27. Other Strategies • Living Well: • Physical activity • Healthy eating • Sleep • Leisure • Focusing/Mindfulness (e.g., Mindful breathing) • Organization & planning skills • Reducing distractibility

28. Referral for a Psychological Assessment • When not to refer: • Pt simply asks for a referral or is curious (should go to private practice, not hospital consultation service) • Pt reports a consistent history of symptoms, no other obvious contaminating factors, and they are a candidate for a trial of medication (e.g., in school) • Pt has many reasons for inattention and a clear diagnosis is unlikely: encourage to go straight to counseling

29. Referral for a Psychological Assessment • When to refer: • You are working actively with a patient and you could really use a psychological assessment of them • Pt can’t be reassured or problems can’t be addressed in a reasonable time frame: pt is complicated and difficult • You suspect ADD is likely and pt is a student who may need documentation

30. Some References • NICE. Attention deficit hyperactivity disorder. Diagnosis and management of ADHD in children, young people and adults (National Clinical Practice Guideline Number 72). National Institute for Health and Clinical Excellence; 2009. http://www.nice.org.uk/nicemedia/live/12061/42060/42060.pdf • SE Sprich,LE Knouse, C Cooper-Vince, J Burbridge, SA Safren. Description and demonstration of CBT for ADHD in adults. Cognitive and Behavioral Practice 2010;17:9-15. • S Moulton Sarkis. 10 simple solutions to adult ADD: How to overcome chronic distraction & accomplish your goals. Oakland, CA: New Harbinger; 2006. • L. Honos-Webb. The gift of adult ADD. How to transform your challenges and build on your strengths. Oakland, CA: New Harbinger; 2008.