Cognitive-behavioral therapy for ADHD people

Attention Deficit Disorder (ADD) and Attention Deficit/Hyperactivity Disorder (ADHD) is getting a lot of attention in children, but it’s widely recognized in adults too: about 4.4 percent of adults in the United States have ADHD. Many of those adults are on medication, but may continue to have symptoms of inattention and impulsiveness that impair their lives. The prognosis for these patients is influenced by the severity of symptoms, comorbidity, I.Q., family situation such as parental pathology, family adversity, socioeconomic status, and treatment.

More than 70 percent of the individuals who have ADHD in childhood continue to have it in adolescence. Up to 50 percent will continue to have it in adulthood. Although it’s been estimated that 6 percent of the adult population has ADHD, the majority of those adults remain undiagnosed, and only one in four of them seek treatment. Yet, without help, adults with ADHD are highly vulnerable to depression, anxiety, and substance abuse. They often experience career difficulties, legal and financial problems, and troubled personal relationships.

COMORBIDITY

A group of researchers, led by Isaac Szpindel, M.D., sought to assess comorbidity types and frequencies and age and gender characteristics in a large sample of children and adolescents ages 3 to 18 years with attention-deficit/hyperacitivity disorder (ADHD) found that among children and adolescents with ADHD, more than 80 percent had a diagnosis of at least one other psychiatric disorder, most commonly oppositional defiant disorder and conduct disorder, according to new research being presented at the American Psychiatric Association’s Annual Meeting (May 25, 2010). ADHD is highly comorbid and exhibits specific age and gender characteristics that evolve with age, the researchers concluded. Understanding of these features can aid in the formulation of differential diagnoses and in the choice of medication in children/adolescents with ADHD.

ADHD is highly comorbid and exhibits specific age and gender characteristics that evolve with age, the researchers concluded. Understanding of these features can aid in the formulation of differential diagnoses and in the choice of medication in children/adolescents with ADHD.

LONG-TERM USE OF METHYLPHENIDATE (PSYCHOSTIMULANTS)

Attention Deficit Disorder is commonly treated with stimulant medications such as Ritalin (methylphenidate), thus psychostimulants are far and away the most popular treatment in young children. ADHD is a serious disorder that has long-term negative consequences on a person’s life. In general, treatment with methylphenidate (psychostimulants) provides some long-term benefit, but it’s not perfect, and most children with ADHD continue to struggle into their teen years, compared with their peers without ADHD.

However, this medication has short-term effects and numerous undesirable side effects. The psychostimulants ordinarily do not cover the entire day, leaving parents at a loss for how to help children manage their symptoms in the evening or on weekends, and may be less efficacious for domain of function, such as peer or family interactions, that involve complex multi-determined interpersonal components. Thus psychosocial treatments also have a large role to play in the treatment of ADD/ADHD.

Treatment, particularly stimulant medication, can be helpful in the short term for patients with ADHD, but the long-term impact of treatment is deemed unclear. The effects of long-term methylphenidate treatment (psychostimulants treatment) on the developing brains of children with ADHD is the subject of study and debate1,2. There is a lack of evidence of the effectiveness in the long term of beneficial effects of methylphenidate with regard to learning and academic performance. The long-term effects on mental health disorders in later life of chronic use of methylphenidate is unknown. There is limited data that suggests there are benefits to long-term treatment in correctly diagnosed children with ADHD, with overall modest risks3. The long term effectiveness of methylphenidate has not been scientifically demonstrated. Tolerance and behavioural sensitisation may occur with long-term use of methylphenidate4. There are no well defined withdrawal schedules for discontinuing long-term use of stimulants5. The withdrawal or rebound symptoms of methylphenidate can include psychosis, depression, irritability and a temporary worsening of the original ADHD symptoms.

The side effects of Ritalin are very frightening. The Physicians Desk Reference lists the possible side effects of taking Ritalin: anorexia, nausea, dizziness, heart palpitations, headache, dyskinesia, drowsiness, blood pressure and pulse changes, tachycardia(racing heart), angina, abdominal pain, restlessness, insomnia, loss of appetite and arrythmia. Hallucinations and toxic psychosis may also occur in patients taking Ritalin. Treatment of ADHD by way of Methylphenidate has led to legal actions including malpractice suits regarding informed consent, inadequate information on side effects, misdiagnosis, and coercive use of medications by school systems. Teachers, parents and doctors continue to advocate Ritalin, and Although Ritalin is not the answer for every child, most physicians use it as their first form of treatment. Pharmopsychology is the most widely used technique to treat ADHD (Rief, 1998).

Some researchs hints that hidden risks might accompany long-term use of the medicines that treat attention-deficit hyperactivity disorder, and a smattering of recent studies, most of them involving animals, hint that stimulants could alter the structure and function of the brain in ways that may depress mood, boost anxiety and, in sharp contrast to their short-term effects, lead to cognitive deficits, thus inappropriate treatment is particularly worrisome because of the unknown impacts of long-term stimulant usage, on children’s health, who are either having, or either not having, ADHD6. Also, research with rats finds that Ritalin at low doses encourages neurons to fire together, but at high doses it’s just another stimulant7.

PSYCHOSOCIAL TREATMENT

A study led by Steven Safren at Massachusetts General Hospital Behavioural Medicine works toward an evidence-based approach to treating adults with the condition. The main therapy tested in this study was a form of cognitive behavioural therapy, which helps people form healthy habits and thought patterns. This therapy targeted three skill sets: problem-solving, reducing distractibility, and dealing with negative thinking and stress associated with the disorder. Participants who went through cognitive behavioural therapy had significantly better outcomes. Safren and colleagues had already published a therapist manual and client workbook detailing their cognitive behavioural therapy method, both called « Mastering Your Adult ADHD, » in 2005.

Skills typically taught during cognitive-behavioral therapy include education about symptoms and medications, emotional regulation, self-esteem building, problem-solving skills, mindfulness and strategies for improving motivation, concentration, listening, impulsivity, organization and time management. It is important to note that pharmacological interventions alone may be insufficient, and thus combining cognitive behavioural therapy is recommended. Family therapy and support groups may also prove a useful adjunct in adult ADHD management.

Dr. Lenard A. Adler noted that adult ADHD affects 4.4% of the US population. « Not only is it common, but most of [those affected] are unrecognized and untreated. We know that anywhere between 10% and 25% of adults with ADHD are actually diagnosed and treated at this time. »8 « If we can improve our diagnostic assessments, the chance that we’re going to be able to bring more people into being diagnosed and treated for a very common and impairing condition should improve, » said Dr. Adler. But when you improve their executive function, it just lets them perform better. Executive Functionning problems are « the most consistent and discriminating predictors » of adult ADHD.

Although medication is the current treatment of choice, many adults with ADHD cannot or will not take medication. In addition, most patients taking medication, although considered responders (defined as patients who experience a ≥30% reduction in ADHD symptoms), continue to experience clinically significant symptoms, highlighting the need for « alternative and next step strategies.

« [ADHD] is a very impairing and distressing disorder, and while medications help, they don’t teach people skills to cope with their problems. This treatment is a relatively easy, short-term, skills-based treatment that teaches patients self-management skills to further reduce their symptoms ». ADHD patients who continue to have symptoms despite medication use should be considered potential candidates for Cognitive behavioral therapy. A previous pilot study of CBT by Dr. Safren and colleagues in this patient population showed those taking medication who received CBT had greater symptom reduction compared with those taking medication alone (Behav Res Ther. 2005;43:831-842).

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SOURCES & RÉFERENCES

1 2003. “ADHD & Women’s health – Attention Deficit/Hyperactivity Disorder”. Available at: http://findarticles.com/p/articles/mi_m0NKT/is_1_25/ai_99698688/pg_4/. [Accessed December 30, 2010].
2Edmund J. S. Sonuga-Barke, Margaret Thompson, Howard Abikoff, Rachel Klein, Laurie Miller Brotman. « Nonpharmacological Interventions for Preschoolers With ADHD: The Case for Specialized Parent Training » (PDF). Infants & Young Children 19 (2): 142–153. While most recent studies suggest that methylphenidate is relatively well-tolerated by young children, some suggest that side-effects might be more marked in preschoolers than in school-aged children (Firestone, Musten, Pisterman, Mercer, & Bennett, 1998). Furthermore, some researchers have argued that there is the potential for negative long-term effects on the developing brains of young children chronically medicated (Moll, Rothenberger, Ruther, & Huther, 2002). ». http://depts.washington.edu/isei/iyc/sonuga_19.2.pdf. Retrieved 2010-12-29.
3Kociancic T, Reed MD, Findling RL (March 2004). « Evaluation of risks associated with short- and long-term psychostimulant therapy for treatment of ADHD in children ». Expert Opin Drug Saf 3 (2): 93–100.
4Patrick KS, Straughn AB, Perkins JS, González MA (January 2009). « Evolution of stimulants to treat ADHD: transdermal methylphenidate ». Human Psychopharmacology 24 (1): 1–17.
5Ashton, H., Gallagher, P. & Moore, B., 2006. The adult psychiatrist’s dilemma: psychostimulant use in attention deficit/hyperactivity disorder. Journal of Psychopharmacology, 20(5), pp.602 -610.
6Higgins Edmund S. (July 2009) “Do ADHD Drugs Take a Toll on the Brain?” Scientific American, http://www.scientificamerican.com/article.cfm?id=do-adhd-drugs-take-a-toll, [Accessed December 30, 2010].
7(July 2008), “Ritalin Dose Changes Effect”, Scientific American http://www.scientificamerican.com/podcast/episode.cfm?id=081535BC-EB62-D649-01B40A271E2C0EDE, [Accessed December 30, 2010].
8Brauser, Deborah. (2010) “Executive Functioning Problems Consistent Predictors of Adult ADHD”, Medscape Medical News, November 2010, http://www.medscape.com/viewarticle/732402, [Accessed Fabuary 26, 2011].

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