Schrevel, S. J. C., Dedding, C., & Broerse, J. E. W. (2016). Why do adults with ADHD choose strength-based coaching over public mental health care? A qualitative case study from the Netherlands. Sage Open, July-September, 1-8. doi: 10.1177/2158244016662498
Overview and Recommendations by David Giwerc, MCAC, MCC
The coaching profession has had a relative scarcity of research documenting the benefits of ADHD Coaching for adults. However, a recently published study conducted in the Netherlands asked adults with ADHD about their experiences with different treatment modalities, including ADHD Coaching. The findings indicated that participants reported that they benefit from strength-based ADHD coaching and cited their dissatisfaction with the other current public mental health care options.
The study was conducted through 23 semi-structured interviews with ADHD clients, all older than 25 years-old, who were recruited from a private coaching center. All but one of the interviewees had an official diagnosis of ADHD, and all but one had experiences with mental health care prior to coaching. Most of them had established, years-long treatment histories and frequently described a series of negative experiences in the mental health care system. Five of the participants were taking prescribed stimulant medications.
The study asked why adults with ADHD prefer to pay out-of-pocket for coaching services rather than receive reimbursed public mental health care that is available to them.
All but one of the study participants cited the high value placed on the “optimistic strength-based and solution-focused approach” of ADHD coaching, which was cited as being different from their experiences in the “symptom-centered approach” of public mental health care. Coaching was perceived as a “joint venture” fostering hope and healing by reinforcing personal strengths and competencies, person-centeredness, and the belief that everyone is capable of overcoming mental illness to live a meaningful life.
Rather than becoming fixated on their problems, many of the participants found that coaching facilitated a simpler approach which encouraged them to search for solutions when confronted with problems. By participating in the coaching process, some participants described a greater sense of control over their pervasive problems by learning coping strategies that what worked for them.
The outcome form ADHD Coaching that was most frequently described by participants was increased insight. Participants noted that community-based therapy enabled them to understand themselves, what they are doing, and how and why they are doing it. In contrast, respondents reported that Coaching “lets you discover who you are, and what you are allowed to be. . . how your internal communication works, how you treat other people. They [coaches] teach you how to enjoy life, something very simple actually.”
This study highlights two important findings. First, some ADHD adults feel their needs are inadequately addressed by the mental health system, and second, these adults appeared to benefit from strength-based, specialized ADHD coaching.
Using a similar methodology, the research can be expanded to other countries in order to identify the perceptions and benefits of strength-based coaching for adults with ADHD.
Of course, the study is limited by the fact that the participants were recruited from a sample of individuals participating in an ADHD Coaching program, thus there is a self-selection bias, as individuals seeking Coaching may have done so because they were dissatisfied by community care. It is also unclear of the nature of community services available to participants in terms of targeting adult ADHD. Future studies may include a representative sample of individuals receiving a range of treatments for adult ADHD. Lastly, the training of the coaching process, specific models, competencies and strategies employed by ADHD Coaches are varied and studies specifying training standards and approaches used by ADHD Coaches will help the generalization of findings from future studies.
Affective lability is a term used in mood disorders where as emotional dysregulation is described in attention deficit hyperactivity disorder. At first glance these two terms might appear to make categorical distinctions yet the clinical presentation is often much more confusing. Richard-Lepouriel and colleagues (2016) wrote in their paper on the similarities of affective lability and emotional dysregulation that emotional dysregulation (term to describe both) can be “defined by excessive expression and experience of emotions with rapid and poorly controlled shift and emotions and abnormal allocation of attention to emotional stimuli.” Yet how can such a descriptive definition be clinically operationalized?
If we look at the DSM diagnostic criteria, there are multiple symptoms that overlap Bipolar Disorder-hypomania/mania and ADHD. In the DSM-IV, Bipolar Disorder/ADHD respective symptoms were more talkative than usual/talks excessively, distractibility/easily distracted, increased activity or physical restlessness/fidgets and restless, loss of normal social inhibitions/interrupts and butts in uninvited. In DSM 5, the symptom overlap continues with hypomanic/manic symptoms of increased talkativeness, racing thoughts, distractibility, psychomotor agitation, increase risky behavior compared to ADHD symptoms of talks too much in social situations, difficulty maintaining attention and distractible, fidgety and restless. And while not diagnostic criteria for ADHD, impulsive risky-taking behavior and sleep disturbance both overlap with Bipolar Disorder. In addition, both disorders require social/occupational distress or impairment be present.
While symptoms are descriptive, the etiology is unaddressed. Is this is a dysfunction with the accelerator (the rapidity of emotional intensity) or the lack of brakes (leading to impulsive expression)? The distinction can have neuropharmacologic implications. For example, the prescription for affective lability in bipolar disorder is a mood stabilizer, while emotional dysregulation in ADHD seems to respond to stimulants and atomoxetine. In contrast, no literature supports the use of ADHD medications for mood control in bipolar disorder and ADHD medications are discouraged in bipolar patients.
Do we learn anything from the pharmacologic action of respective disease appropriate medications? Not really. If we apply the concept of “dysfunctional accelerator”, mood stabilizers as lithium, lamotrigine, carbarmazepine, valproate, and atypical neuroleptics have different pharmacologic action, although the epileptic medications have the commonality of anti-seizure effect. At one time, it was thought that the anti-seizure characteristic was an explanation for the mood stabilization. However, the hypothesis of kindling has not proven to be a credible explanation for bipolar disorder after decades of research. Mood stabilizer heterogeneity may be in contrast to stimulant medications all of which have the commonality of increasing cerebral dopamine levels. Considering the “lack of brakes” concept, one might presume that elevations in dopamine levels mitigate emotional dysregulation by “applying the brakes” to impulsive emotional expression. And yet, while atomoxetine and alpha agents have downstream effects on dopamine that presumably explains their efficacy, their benefit on emotional regulation may result from the direct effect on noradenline or a neural system not yet identified.
I submit that affective lability and emotional dysregulation represents a conceptual difference without a clinical distinction. As a result, the use of symptom checklists at a single point in time is likely to render a compromised diagnosis. The response to medication is unlikely to provide any greater accuracy in diagnosis. What have been missing from DSM criteria have been the age of onset, longitudinal course of symptoms, and the presence of the symptoms/disorder in first-degree relatives. These three historical factors will increase the specificity of the diagnosis.
While there will be much debate over “who owns” emotional dysfunction, the mood disorder camp or the ADHD camp, the clinical use of emotional expression as a predominant determinant of the disorder will lead us astray.
David W. Goodman, M.D.
Richard-Lepouriel H, et al. Similarities between emotional dysregulation in adults suffering from ADHD and bipolar patients. J Affect Dis. 2016. 198:230-236.
Bender RE, et al. Life stress and kindling in bipolar disorder: review of the evidence and integration with emerging biopsychosocial theories. Clin. Psychol. Rev. 2011. 31: 383–398.
This is an everyday issue in real world clinical practice.
The old adage of “Treat mood and anxiety first” before treating ADHD has long been considered the recommended standard of care when confronted with patients with ADHD comorbid with significant mood or anxiety symptoms.
Recent findings by Chen et al from a nationwide longitudinal study of ADHD and comorbid major depression (MDD/ADHD) may cause clinicians to rethink this strategy. Their study identified 1,891 patients with MDD/ADHD and compared them with 1,891 age and sex matched patients with major depression only in a 1-year longitudinal study. Patients with MDD/ADHD had 232% the risk of treatment resistance to multiple antidepressants compared with patients with major depression without ADHD. Their study went on to find that individuals receiving regular treatment for ADHD had a significantly lower risk for antidepressant treatment resistance. In conclusion, “Patients who had dual diagnoses of major depression and attention deficit hyperactivity disorder were more likely to have treatment resistance to antidepressants… prompt and regular treatment for attention deficit hyperactivity disorder would reduce this risk”.
This study highlights the fact that when ADHD symptomatology are driving functional impairments and exacerbating underlying mood disorders, anxiety disorders or substance abuse, that concomitant treatment of ADHD and these associated conditions often yields the best overall therapeutic response.
How will these findings influence your clinical practice?
How do these results change the way we teach our colleagues to manage patients with depression and co-ocurring ADHD?
Greg Mattingly MD
Chen et al. Eur Neuropsychopharmacol. 2016 Sep 22. pii: S0924-977X(16)30562-4. doi: 10.1016/j.euroneuro.2016.09.369. [Epub ahead of print] Attention – deficit hyperactivity disorder comorbidity and antidepressant resistance among patients with major depression: A nationwide longitudinal study.
The comorbidity between attention deficit hyperactivity disorder ( ADHD ) and major depression is common. However, the influence of ADHD comorbidity in the response or resistance to antidepressants remains unknown among patients with major depression. 1891 patients with major depression and ADHD and 1891 age-/sex-matched patients with major depression only were enrolled and followed for 1 year in our study. Use of antidepressants and ADHD medications during 1-year follow-up period were assessed. Antidepressant resistance was defined as treatment failure in two or more than two different antidepressants for adequate treatment dose and duration. Patients with major depression and ADHD had an increased risk of treatment resistance to antidepressants (odds ratio [OR]: 2.32, 95% confidence interval [CI]: 1.63-3.32) compared with patients with major depression only after adjusting for demographic characteristics and other psychiatric comorbidities. Regular treatment for ADHD would reduce this risk (OR: 1.76, 95% CI: 0.72-4.27).
Anxiety (OR: 3.15, 95% CI: 2.24-4.44) and substance use (OR: 2.45, 95% CI: 1.16-5.17) disorders were also associated with an elevated likelihood of resistance to antidepressants during the follow-up. Patients who had dual diagnoses of major depression and ADHD were more likely to have treatment resistance to antidepressants compared with patients with major depression only. Prompt and regular treatment for ADHD would reduce this risk.