Sep 11, 2018 | Research Updates
As part of the mission of the APSARD Psychosocial Treatment Committee, the committee members will share blogs related to issues relevant to non-medical treatments for ADHD.
J. Russell Ramsay, Ph.D.
Associate Professor of Clinical Psychology
University of Pennsylvania, Perelman School of Medicine
Implementation intentions stem from a line of self-regulation research focused on the observation that a purely goal-focused approach to behavior change does not inexorably produce actions necessary to achieve that goal (Gollwitzer, 1999). Consequently, more specific, action-oriented plans designed for specific contexts (and tied to an overarching goal) have been found to improve follow through. These plans are framed in “If X, then Y” conditional statements in which a specific action or obstacle is tied with a specific setting, such that the setting itself then provides a cue for the desired action: “If situation X is encountered, then I will perform the goal-directed response Y!” (Gollwitzer & Oettingen, 2016, p. 223). Thus, someone with the goal of losing weight might identify that he is prone to snacking after seeing someone at work eating candy from the vending machine. His implementation intention might be “If I have the urge to go to the vending machine, then I will go get water or coffee instead.” The theory is that the vending machine becomes a cue for the coping response.
Although not yet studied in adults with ADHD, non-clinical studies of implementation intentions with children with ADHD indicate that they promote better task follow through (Gawrilow, Gollwitzer, & Oettingen, 2011a, 2011b; Gawrilow et al., 2013). The “If X, Then Y” (or “When X, Then Y,” if using “possibility language”) strategy has been a facet of our CBT approach for adult ADHD and it has been a valuable intervention domain (Ramsay & Rostain, 2015). In a small open study of adults with ADHD who completed CBT without medication, significant improvements on an activation measure were achieved, consistent with this and other implementation tenets (Ramsay & Rostain, 2011).
Procrastination is arguably the most common problem faced by adults with ADHD. Specific implementation plans can be designed for the initial behavioral step of task engagement, such as for a college student: “If I can get to the library, then I can open my economics assignment.” These statements are particularly useful for managing the pivot points within a task plan, such as defining the step for returning to the task after a brief break (“When I finish my coffee, then I can re-read the last few sentences I wrote to get re-engaged.”). Implementation plans can also be designed for re-engaging in tasks after being distracted, dealing with rationalizations for escaping a task, managing obstacles (“If the main section of the library is crowded, then I will take the elevator to the 5th floor stacks.”), or navigating other “tipping points” that represent risks for somehow getting distracted from one’s objectives.
The implementation plan or the “If/When X-Then Y plan,” is a useful, “sticky” take-away skill. These reminders can be externalized if the form of coping cards or other means to increase the likelihood of engagement in and follow through on tasks and endeavors.
References
Gawrilow, C., Gollwitzer, P. M., & Oettingen, G. (2011a). If-then plan benefit delay of gratification performance in children with and without ADHD. Cognitive Therapy and Research, 35, 442-455. doi: 10.1007/s10608-010-9309-z
Gawrilow, C., Gollwitzer, P. M., & Oettingen, G. (2011b). If-then plans benefit executive functions in children with ADHD. Journal of Social and Clinical Psychology, 30, 616-646.
Gawrilow, C., Morgenroth, K., Schultz, R., Oettingen, G., & Gollwitzer, P. M. (2013). Mental contrasting with implementation intentions enhances self-regulation of goal pursuit in schoolchildren at risk for ADHD. Motivation and Emotion, 37, 134-145. doi: 10.1007/s11031-012-9288-3
Gollwitzer, P. M. (1999). Implementation intentions: Strong effects of simple plans. American Psychologist, 54, 493-503.
Gollwitzer, P. M., & Oettingen, G. (2016). Planning promotes goal striving. In K. D. Vohs, & R. F. Baumeister (Eds.), Handbook of self-regulation: Research, theory, and applications (3rd ed.) (pp. 223-244). New York: Guilford.
Ramsay, J. R., & Rostain, A. L. (2011). CBT without medications for adult ADHD: An open pilot study of five patients. Journal of Cognitive Psychotherapy: An International Quarterly, 25, 277-286. doi: 10.1891/0889-8391.25.4.277
Ramsay, J. R., & Rostain, A. L. (2015). Cognitive behavioral therapy for adult ADHD: An integrative psychosocial and medical approach (2nd ed.). New York: Routledge.
Jul 31, 2018 | Editorial
Gregory Mattingly MD
Associate Clinical Professor,
Washington University
President, Midwest Research Group
In a world where each of us spends many hours per day “connected” one must ponder how high intensity digital stimulation modifies the brain and behavior. Not only adults but children are continuously exposed by their phones “blowing up” with group texts, snap chat, instagram and the like.
Our modern digital age comes with many advances but important questions remain:
Does social media influence my child’s attention?
Does being “logged on “ increase my child’s chance of having ADHD?
Does a digital world have an effect on ADHD?
How many times have each of us pondered these questions?
How do you best answer a patient or family?
A recent article in JAMA Psychiatry explored these issues in a study of 3,051 15 to 16 year old 10th grade students. (JAMA. 2018;320(3):255-263) At 2 year follow up, children who did not meet criteria for ADHD at baseline were examined to see if their level of high frequency digital media use influenced their development of ADHD symptoms.
At 2 year follow up, those with low digital media use had a 4.6% rate of ADHD like symptoms, those with moderate use had a 9.5% rate and those with high frequency digital media activities had a 10.5% rate of ADHD like symptoms.
This study raises many intriguing questions:
Do short bursts of digital stimulation increase the rate of developing ADHD or ADHD like symptoms?
Are individuals with subsyndromal ADHD drawn to high frequency digital media activities?
Does our digital world increase the risk of ADHD?
Could sustained digital stimulation with increasing cognitive demands; as in the Akili intervention decrease the development of such symptoms? (JAMA Published online June 13, 2018)
In short, is the brain malleable to digital stimulation? Do brief quantas of high stimulus activity prime the brain to desire brief high stimulus activity and perhaps impair the ability to maintain sustained attention during low stimulus activities? Do certain digital activities increase the risk of ADHD symptoms and others build resilience against such symptoms?
Fascinating questions that excite and intrigue our field and the patients for whom we care.
Jul 24, 2018 | Interview
APSARD Board Member, Anthony Rostain, M.A., M.D., was interviewed by Healio Psychiatry. Please see below for the introduction and the link to the full article.
CLICK HERE TO ACCESS THE FULL INTERVIEW
“ADHD is marked by a pattern of inattention and/or hyperactivity-impulsivity that affects daily functioning. According to data from the National Comorbidity Survey Replication, the overall prevalence of adult ADHD in the U.S. is 4.4%, and the estimated lifetime prevalence among those aged 18 to 44 years is 8.1%.
Diagnosing, and subsequently treating, adult ADHD requires a multifaceted approach that includes a thorough evaluation, consideration of cooccurring conditions, patient education and weighing of risks and benefits of treatment with stimulants on a case-by-case basis.
Healio Psychiatry spoke with Anthony L. Rostain, MD, professor of psychiatry at the Hospital of the University of Pennsylvania and the Children’s Hospital of Philadelphia, for clinical guidance on the who, what, when and how of prescribing stimulants. – by Stacey Adams”
Jul 9, 2018 | Editorial
J.J. Sandra Kooij, M.D., Ph.D. Associate Professor of Psychiatry at VUMc, Amsterdam
In 2002, I founded Program and Expertise Center Adult ADHD at Parnassia, later PsyQ, the Hague, The Netherlands. The aim was to serve patients, to teach colleagues in assessment and treatment, and to do research to increase knowledge on this highly frequent disorder in adult psychiatry (www.psyq.nl). We started with a team of 5 professionals and 100 adult patients, and we currently treat around 1000 patients annually with a team of 45 professionals. Meanwhile PsyQ, a mental health care provider that offers specialized programs for 10 disorders, expanded to 34 locations around the country, and we got the chance to educate every team about adult ADHD. In addition, every referred patient was screened for ADHD (and other disorders) before entering the system. This way, matched care was delivered, even when patients or their GPs were not aware of their condition(s). This pioneering process is described in more detail in my book Adult ADHD. Diagnostic Assessment and Treatment (2012, Springer).
The team had to develop everything, from the Diagnostic Interview for ADHD in adults (DIVA 2.0), to methods for psycho-education, medication management, coaching and group CBT
The National PsyQ ADHD Team in 2013 at the 10 year anniversary
ADHD Network
Meanwhile, we had started the Adult ADHD Network for professionals, that later fused with the Child ADHD Network of pediatricians and psychiatrists. This new ‘ADHD Network‘ reflects the lifespan perspective of ADHD.
(www.adhdnetwerk.nl).
European Network Adult ADHD
Also the European Network Adult ADHD (ENAA) was founded in 2002, to exchange knowledge and experience, and inspire professionals in the same pioneering position around Europe. ENAA currently unites 74 professionals from 28 countries (www.eunetworkadultadhd.com). This network published its first Consensus Statement on Diagnosis and Treatment of Adult ADHD in 2010. The updated, open access version has just been submitted.
DIVA Foundation
The DIVA Foundation started distributing the DIVA 2.0 in Dutch for free from 2007 to lower the threshold for appropriate assessment of ADHD in adults. The interview is now available in 20 languages worldwide (www.divacenter.eu). Due to the increased license fee by the APA for use of the DSM-criteria, it may be necessary in the near future to ask payment for downloads. There is also a DIVA 2.0 app available in the App and Google stores that contains all languages. The DIVA 2.0 was validated in 2 studies and is increasingly used in research. The next edition, DIVA-5, based on the DSM-5 criteria is underway in many languages.
Top Mental Health acknowledgement
In 2008, the Program and Expertise Center was acknowledged the Top Mental Health status in the Netherlands (www.topggz.nl), for excellent patient care, innovative research and education on adult ADHD. The work of the team is re-evaluated every 3 years and has prolonged this Top Mental Health acknowledgement up to today.
Lifespan ADHD Clinic
In 2011, we started the Lifespan ADHD clinic together with Lucertis, a child and adolescent mental health care provider. The aim was to bring parents and children together at the same location for treatment, to be able to work more closely together, to take better care of adolescents who tend to quit treatment at age 15, and to develop care for older people with ADHD. The idea was highly appreciated by patients and professionals, but proved difficult to organize due to different financial and organizational systems and different management. We are still trying to become one team with one budget to overcome these difficulties.
Research
Our research at the Expertise Center Adult ADHD in close cooperation with the Dept. of Psychiatry at VUMc Amsterdam, is currently focused on late sleep in ADHD and the impact on health in the long term, as well as on hormonal mood changes during the lifespan in women with ADHD. Older people (> age 60) were shown in our research to still suffer from ADHD in around 3% of the Dutch population, and we are now developing a treatment protocol, and evaluating the treatment wishes of this group and their response to stimulants.
Education
The Expertise Center Adult ADHD educated mental health care professionals and GPs annually with 20 (inter)national courses and several lectures at symposia on assessment and treatment of ADHD in adults and older people, and currently with a new course on Sleep and ADHD.
The Expertise Center participated with the ADHD Network in:
– online national education on adult ADHD for residents in psychiatry
– the Guideline for ADHD in adults of the Dutch Organisation of Psychiatry, that was published in 2015.
Digital Medicine: Super Brains for ADHD
Next step will be to improve access to care for the unmet need of ADHD patients by Digital Medicine: the ADHD app Super Brains, that can be used by patients on their own, as well is for blended care during professional treatment. The app contains self-tests, psycho-education on ADHD and comorbidities, coaching and CBT interventions, reminders, video chats, communities with other experience experts and professionals, lifestyle habits, and gamification. The expectation is that treatment may be more intensive, more effective and of shorter duration. The idea for Super Brains comes from an ICT company owner with ADHD, Rutger den Hollander, who wanted to develop digital medicine for himself, his family, and the rest of the world. PsyQ is investing in its development, and insurance companies are adopting the concept. Super Brains will be launched in the Netherlands this year, first for adults with ADHD, then for children and their parents. Other patient groups are waiting to adjust the app to their needs. Super Brains will be made available in English too. You will be informed by a new blog at that time!
Jul 9, 2018 | Editorial
J. Russell Ramsay, Ph.D.
Associate Professor of Clinical Psychology
University of Pennsylvania, Perelman School of Medicine
Below is a link to an interesting article relevant to the psychosocial treatment of adult ADHD, particularly using cognitive behavioral therapy oriented approaches. A previous blog by this writer (Core Beliefs and Adult ADHD, 03/15/2017) highlighted two preliminary studies of the incidence of maladaptive schema in adults with ADHD and their potential contribution to difficulties following through on the effective implementation of coping strategies that are known to be helpful.1,2
Drawing on these the studies, the authors of the current paper consider the clinical implications of these initial findings.3 They highlight that a focus on schema and relevant interventions should be viewed as an extension of existing CBT approaches for adult ADHD. The authors note that while providing a clinically-informed tailoring of psychosocial treatment to individual cases, this very individualization makes it more difficult, though not impossible to conduct controlled research, witness a recent randomized outcome study of a tailored case-conceptualization based CBT approach for adult ADHD.4
References
1 Miklosi, M., Máté, O., Somogyi, K., & Szabó, M. (2016). Adult attention deficit hyperactivity disorder symptoms, perceived stress, and well-being. The Journal of Nervous and Mental Disease, 204, 364-369. doi: 10.1097/NMD.0000000000000472
2 Philipsen, A., Lam, A. P., Breit, S., Lücke, C., Müller, H. H., & Matthies, S. (2017). Early maladaptive schemas in adult patients with attention deficit hyperactivity disorder Attention Deficit Hyperactivity Disorder, 9, 101-111. doi: 10.1007/s12402-016-0211-8
3 Lücke, C., Lam, A. P., Müller, H. H. O., & Philipsen, A. (2017). New psychotherapeutic approaches in adult ADHD – acknowledging biographical factors. Journal of Neurology & Neuromedicine, 2(7), 6-10.
4 Dittner, A. J., Hodsoll, J., Rimes, K. A., Russell, A. J., & Chalder T. (2018) Cognitive–behavioural therapy for adult attention-deficit hyperactivity disorder: a proof of concept randomised controlled trial. Acta Psychiatrica Scandinavica, 137, 125-137. doi: 10.1111/acps.12836
Link to article reviewed above:
http://www.jneurology.com/articles/new-psychotherapeutic-approaches-in-adult-adhd–acknowledging-biographical-factors.html
