Psychotherapy and ADHD: How a Harvard Professor Help his Patients
Professor Larry Seidman is world renowned for his neuropsychology and neuroimaging research. In addition to all of his creative science, he has found the time to create what he calls “Neuropsychologically Informed Strategic Psychotherapy (NISP) in Teenagers and Adults with ADHD.” Let’s start with what NISP is not. NISP is not cognitive behavior therapy (CBT). CBT emphasizes teaching patients to identify thinking patterns that lead to problem behaviors. NISP describes how the interpersonal interaction we call psychotherapy can help patients increase self-regulation and self-control. NISP treatments vary in duration from brief psycho-educational interventions of one to five sessions to much longer term therapies of indefinite duration. The duration of therapy is tailored to the needs and goals of the individual. The methods of NISP can be adaptively applied into well-known therapy modalities such as CBT and family therapy. By creating a solid therapeutic alliance, NISP improves adherence to medications and addresses ADHD’s psychiatric comorbidities and functional disabilities. NISP is “neuropsychologically informed” because it follows a comprehensive neuropsychological assessment of strengths and weaknesses. This leaves the therapist with an understanding of the patient’s personal experience of ADHD, the meaning of the disorder, how it affects self-esteem, and how cognitive deficits limit the ability to self-regulate and adapt to changing circumstances. Attending to the patient’s strengths is a key feature of Prof. Seidman’s method. ADHD is a disorder and it usually has serious consequences. But ADHD people also have strong points in their character and their neuropsychological skills. These sometimes get lost in assessments of ADHD but, as Dr. Seidman indicates, by addressing strengths, patient outcomes can be improved. A NISP assessment also seeks to learn about the psychological themes that underlie each patient’s story. He gives the all too common example of the patients who view themselves as failed children who have not tried hard enough to succeed. A frank discussion of neuropsychological test results can be the first step to helping patients reconceptualize their past and move on to an adaptive path of self-understanding and self-regulation.
Prof. Seidman’s approach seems sensible and promising. As he recognizes, it has not yet, however, been subject to the rigorous tests of evidenced-based medicine (my blog on EBM: http://tinyurl.com/ne4t7op). So I would not recommend using it as a replacement for an evidenced-based treatment. That said, if you are a psychotherapist who treats ADHD people, read Prof. Seidman’s paper. It will give you useful insights that will help your patients.
Seidman, L. J. (2014). Neuropsychologically Informed Strategic Psychotherapy in Teenagers and Adults with ADHD. Child Adolesc Psychiatr Clin N Am 23, 843-852. (In: Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.)
If you’ve been reading my blogs about ADHD, you know that I play by the rules of evidenced based medicine. My view is that the only way to be sure that a treatment ‘works’ is to see what researchers have published in scientific journals. The highest level of evidence is a meta-analysis of randomized controlled clinical trials. For my lay readers, that means that that many rigorous studies have been conducted and summarized with a sophisticated mathematical method.
If you are interested in fish oil as a treatment for ADHD, there is some good news. Many good studies have been published and these have been subjected to meta-analysis. To be more exact, we’re discussing omega-3 polyunsaturated fatty acids (PUFAs), which are found in many fish oils. Omega-3 PUFAs reduce inflammation and oxidative stress, which is why they had been tested as treatments for ADHD. When these studies were meta-analyzed, it became clear that omega-3 PUFAs high in eicosapentaenoic acid (EPA) helped to reduce ADHD symptoms. For details see: Bloch, M. H. and J. Mulqueen (2014). “Nutritional supplements for the treatment of ADHD.” Child Adolesc Psychiatr Clin N Am 23(4): 883-897.
So, if omega-3 PUFAs help reduce ADHD symptoms, why are doctors still prescribing ADHD drugs? The reason is simple. Omega-3 supplements work, but not very well. On a scale of one to 10 where 10 is the best effect, drug therapy scores 9 to 10 but omega-3 therapy scores only 2. Some patients or parents of patients might want to try omega-3 therapy first in the hopes that it will work well for them. That is a possibility, but if that is your choice, you should not delay the more effective drug treatments for too long in the likely event that omega-3 therapy is not sufficient. What about combining ADHD drugs with omega-3 supplements? We don’t know. I hope that future research will see if combined therapy might reduce the amount of drug required for each patient.
Keep in mind that the treatment guidelines from professional organization point to ADHD drugs as the first line treatment for ADHD. The only exception is for preschool children where medication is only the first line treatment for severe ADHD; the guidelines recommend that other preschoolers with ADHD be treated with non-pharmacologic treatments, when available. You can learn more about non-pharmacologic treatments for ADHD from a book I recently edited: Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.
Myth: The ADHD diagnosis is very much “in the eye of the beholder.”
This is one of many ways in which the ADHD diagnosis has been ridiculed in the popular media. The idea here is that because we cannot diagnose ADHD with an objective brain scan or a blood test, the diagnosis is “subjective” and subject to the whim and fancy of the doctor making the diagnosis.
Fact: The ADHD diagnosis is reliable and valid.
The usefulness of a diagnosis does not depend on whether it came from a blood test, a brain test or from talking to a patient. A test is useful if it is reliable, which means that two doctors can agree who does and does not have the disorder, and if it is valid, which means that the diagnosis predicts something that is important to the doctor and patient such as whether or not the patient will respond to a specific treatment. Many research studies show that doctors usually agree about who does and does not have ADHD. The reason for this is that we have very strict rules that one must use to make a diagnosis. Much work over many decades has also shown ADHD to be a valid diagnosis. For details see: Faraone, S. V. (2005). The scientific foundation for understanding attention-deficit/hyperactivity disorder as a valid psychiatric disorder. Eur Child Adolesc Psychiatry 14, 1-10. The short story is that the diagnosis of ADHD is very useful for predicting what treatments will be effective and what types of problems ADHD patients are likely to experience in the future.
Myth: ADHD is not a medical disorder. It’s just the extreme of normal childhood energy
The mental health professions use the term “disorder” to describe ADHD, but others argue that what we view as a disorder named ADHD is simply the extreme of normal childhood energy. After all, most healthy children run around and don’t always listen to their parents. Doesn’t the ADHD child or adult simply have a higher dose of normal behavior?
Fact: Doctors have good reasons to describe ADHD as a disorder
The idea that the extreme of a normal behavior cannot be a disorder is naïve. Consider hypertension (high blood pressure). Everyone has a blood pressure, but when blood pressure exceeds a certain value, doctors get worried because people with high values are at risk for serious problems, such as heart attacks. Consider depression. Everyone gets sad from time to time, but people who are diagnosed with depression cannot function in normal activities and, in the extreme, are at risk for killing themselves. ADHD is not much different from hypertension or depression. Many people will show some signs of ADHD at some times but not all have a “disorder.” We call ADHD a disorder not only because the patient has many symptoms but also because that patient is impaired, which means that they cannot carry out normal life activities. For example, the ADHD child cannot attend to homework or the ADHD adult cannot hold a job, despite adequate levels of intelligence. Like hypertension, untreated ADHD can lead to serious problems such as failing in school, accidents or an inability to maintain friendships. These problems are so severe that the US Center for Disease Control described ADHD as “a serious public health problem.”
Myth: The ADHD diagnosis was developed to justify the use of drugs to subdue the behaviors of children.
This is one of the more bizarre myths about ADHD. The theory here is that, in order to sell more drugs, pharmaceutical companies invented the diagnosis of ADHD to describe normal children who were causing some problems in the past.
Fact: ADHD was discovered by doctors long before ADHD medications were discovered.
People who believe this myth do not know the history of ADHD. In 1798, long before there were any drugs for ADHD, Alexander Crichton, a Scottish doctor described a “disease of attention,” which we would not call ADHD. ADHD symptoms were described by a German doctor, Heinrich Hoffman, in 1845 and by a British doctor, George Still, in 1902. Each of these doctors found that inattentive and overactive behaviors could lead to a problem that should be of concern to doctors. If they had had medications to treat ADHD they probably would have prescribed them to their patients. But a medication for ADHD was not discovered until 1937 and even then, it was discovered by accident. Dr. Charles Bradley from Providence Rhode Island had been doing brain scanning studies of troubled children in a hospital school. The scans left the children with headaches that Dr. Bradley thought would be relieved by an amphetamine drug. When he gave this drug to the children after the scan, it did not help their headaches. However, the next day, their teachers reported that the children were attending and behaving much better in the classroom. Dr. Bradley had accidentally discovered that amphetamine was very helpful in reducing ADHD symptoms and, in fact, amphetamine drugs are commonly used to treat ADHD today. So, as you can see, the diagnosis of ADHD was not “invented” by anyone; it was discovered by doctors long before drugs for ADHD were known.
Myth: Brain scans or computerized tests of brain function can diagnose ADHD.
Someday, this myth may become fact, but for now and the near future it is a solid myth. You may think this is strange. After all, we know that ADHD is a brain disorder and that neuroimaging studies have documented structural and functional abnormalities in the brains of patients with ADHD. If ADHD is a biological disorder, why don’t we have a biological test for the diagnosis?
Fact: No brain test has been shown to accurately diagnose ADHD.
ADHD is a biologically based disorder, but there are many biological changes and each of these is so small that they are not useful as diagnostic tests. We also think that there are several biological pathways to ADHD. That means that not all ADHD patients will show the same underlying biological problems. So for now, the only officially approved method of diagnosing ADHD is by asking patients and/or their parents about ADHD symptoms as described in the American Psychological Associations Diagnostic and Statistical Manual.
As a researcher who has devoted most of the past three decades to studying ADHD, I am surprised (and somewhat embarrassed) to see how little research has focused on how ADHD affects the romantic side of life. There are over 25,000 articles about ADHD listed on www.pubmed.gov, but only a few have provided data about love, sex and ADHD. Bruner and colleagues studied ADHD symptoms and romantic relationship quality in 189 college students. Those students who had high levels of both hyperactivity-impulsivity and inattentiveness reported that the quality of their romantic relationships was relatively low compared with students who had low levels of ADHD symptoms. Another study of 497 college students found that ADHD symptoms predicted a greater use of maladaptive coping strategies in romantic relationships and less romantic satisfaction. A study of young adults compared conflict resolution and problem-solving in romantic couples. It found that ADHD symptoms were associated with greater negativity and less positivity during a conflict resolution task and that higher symptoms predicted less relational satisfaction. But this was not true of the ADHD member of the couple only had inattentive symptoms, which suggests that the severity of ADHD symptoms might drive relationship problems. Unlike the studies of adults, the romantic relationships of adolescents with and without ADHD did not differ on levels of aggression or relationship quality, although only one study addressed this issue.
What about sex? The study of adolescents found that, irrespective of gender, adolescents with ADHD had nearly double the number of lifetime sexual partners. That finding is consistent with Barkley’s follow-up study of ADHD children. He and his colleagues found that ADHD predicted early sexual activity and early parenthood. Similar findings were reported by Flory and colleagues in retrospective study of young adults. Childhood ADHD predicted earlier initiation of sexual activity and intercourse, more sexual partners, more casual sex, and more partner pregnancies. When my colleagues and I studied 1001 adults in the community, we found that adults with ADHD endorsed less stability in their love relationships, felt less able to provide emotional support to their loved ones, experienced more sexual dysfunction and had higher divorce rates.
The research literature about love, sex and ADHD is small, but it is consistent.
Bruner, M. R., A. D. Kuryluk, et al. (2014). “Attention-Deficit/Hyperactivity Disorder Symptom Levels and Romantic Relationship Quality in College Students.” J Am Coll Health: 1-11.
Biederman, J., S. V. Faraone, et al. (2006). “Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community.” J Clin Psychiatry 67(4): 524-540.
Canu, W. H., L. S. Tabor, et al. (2014). “Young Adult Romantic Couples’ Conflict Resolution and Satisfaction Varies with Partner’s Attention-Deficit/Hyperactivity Disorder Type.” J Marital Fam Ther 40(4): 509-524.
Rokeach, A. and J. Wiener (2014). “The Romantic Relationships of Adolescents With ADHD.” J Atten Disord.
Barkley, R. A., M. Fischer, et al. (2006). “Young adult outcome of hyperactive children: adaptive functioning in major life activities.” J Am Acad Child Adolesc Psychiatry 45(2): 192-202.
Flory, K., B. S. Molina, et al. (2006). “Childhood ADHD predicts risky sexual behavior in young adulthood.” J Clin Child Adolesc Psychol 35(4): 571-577.
Overbey, G. A., W. E. Snell, Jr., et al. (2011). “Subclinical ADHD, stress, and coping in romantic relationships of university students.” J Atten Disord 15(1): 67-78.
A recent paper by Margaret Sibley and colleagues addresses a key issue in the diagnosis of adult ADHD. Is it sufficient to only collect data from the patient being diagnosed or are informants useful or, perhaps, essential, for diagnosing ADHD in adults. Dr. Sibley presented as systematic review of twelve studies that prospectively followed ADHD children into adulthood. Each of these studies asked a simple question: What faction of ADHD youth continued to have ADHD in adulthood. Surprisingly, the estimates of ADHD’s persistence ranged from a low of 4% to a high of 77%. They found two study features that accounted for much of this wide range. The first was the nature of the informant; did the study rely only on the patient’s report or were other informants consulted. The second was the use of a strict diagnostic threshold of six symptoms. When they limited the analysis to studies that used informant and eliminated the six symptom threshold, the range of estimates was much narrower, 40% to 77%. From studies that computed multiple measures of persistence using different criteria, the authors concluded: “(1) requiring impairment to be present for diagnosis reduced persistence rates; (2) a norm-based symptom threshold led to higher persistence than a strict six-symptom DSM-based symptom count criterion; and (3) informant reports tended to show a higher number of symptoms than self-reports.” These data have clear implications for what clinicians can do to avoid false positive and false negative diagnoses when diagnosing adult ADHD. It is reassuring that the self-reports of ADHD patients tend to underestimate the number and severity of ADHD symptoms. This means that your patients are not typically exaggerating their symptoms. Put differently, self-reports will not lead you to over-diagnose adult ADHD. Instead, reliance on self-reports can lead to false negative diagnoses, i.e., concluding that someone does not have ADHD when, in fact, they do. You can avoid false negatives by doing a thorough assessment, which is facilitated by some tools available at www.adhdinadults.com and described in CME videos there. If you think a patient might have ADHD but are not certain, it would be helpful to collect data from an informant, i.e., someone who knows the patient well such as a spouse, partner, roommate or parent. You can collect such data by sending home a rating scale or by having the patient bring an informant to a subsequent visit. Dr. Sibley’s paper also shows that you can avoid false negative diagnoses by using a lower symptom threshold than what is required in the diagnostic manual. In fact, the new DSM 5 lowered the symptom threshold for adults from six to five. Can you go lower? Yes, but it is essential to show that these symptoms lead to clear impairments in living. Importantly, this symptom threshold refers to the number of symptoms documented in adulthood, not to the number of symptoms retrospectively reported in childhood. To be diagnosed with ADHD in adulthood, one must document that the patient had at least six impairing symptoms of ADHD prior to the age of 12.
Sibley, M. H., Mitchell, J. T. & Becker, S. P. (2016). Method of adult diagnosis influences estimated persistence of childhood ADHD: a systematic review of longitudinal studies. Lancet Psychiatry 3, 1157-1165.