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ADHD
TREATMENT

Help for developing a plan for treating
and managing your ADHD

TREATMENT

Developing a Management Plan

The primary goal of an ADHD management plan is to control the core symptoms of inattention and hyperactivity/impulsivity. A multimodal management plan that incorporates a variety of strategies may work best for many patients with ADHD.1

A multimodal plan may include2-7:

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PHARMACOLOGIC
THERAPY

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COGNITIVE BEHAVIORAL
THERAPY

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ADHD COACHING AND
OTHER SKILLS-TRAINING
PROGRAMS

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PATIENT EDUCATION
(PSYCHOEDUCATION)

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COMMUNITY RESOURCES
AND ACCOMMODATIONS

Not all interventions are appropriate for all patients.

EACH MANAGEMENT PLAN SHOULD BE INDIVIDUALIZED BASED ON THE HEALTHCARE TEAM’S ASSESSMENT OF4,8:

Level of potential effects

Each patient’s specific
needs and desires

Presence of coexisting disorders and general health of patient

Given the complex nature of ADHD, it is important to construct a management plan that2,4,8

  • Is comprehensive, involving patients, their families, and healthcare professionals
  • Is multimodal, potentially using both pharmacologic and nonpharmacologic interventions when appropriate
  • Takes into account that ADHD is a chronic disorder
  • Provides a means to monitor progress

TREATMENT

PHARMACOLOGIC THERAPIES

MANAGEMENT OF ADHD IN ADULTS WITH PHARMACOTHERAPY*

Medication may be an important part of the management plan for patients with ADHD. There are FDA-approved treatment options that may help improve ADHD symptoms.2

STIMULANTS

  • Amphetamine
  • Methylphenidate

NONSTIMULANTS

  • Selective norepinephrine dopamine reuptake inhibitor

*Pharmacologic treatment may not be appropriate for all patients. Reassess pharmacotherapy periodically.

There are no official US guidelines for the treatment of ADHD in adults.

UNDERSTAND AND COMMUNICATE EXPECTATIONS REGARDING PHARMACOLOGIC THERAPY

TREATMENT MUST
BE INDIVIDUALIZED7

  • The patient and physician need to work together to determine whether medication is appropriate and, if so, identify the right medication for the individual

OPTIMIZING ADHD TREATMENT MAY
TAKE TIME2

  • Physicians may need to try different dosages of a medication, or they may need to try more than one medication to find an optimal treatment

Individuals may respond differently to different medications. It is important to closely monitor symptom improvement and medication side effects for each patient to tailor the individual management plan to the current needs.

Reassess pharmacotherapy periodically


Only qualified health care professionals can prescribe medications to treat ADHD.

TREATMENT

NONPHARMACOLOGIC THERAPIES

NONPHARMACOLOGIC STRATEGIES FOR MANAGING ADHD IN ADULTS

Several nonpharmacologic interventions may help with ADHD symptoms. These interventions can be used as part of a management plan that may or may not include medication as a part of therapy.‡2,7,9

PSYCHOEDUCATION

Education about ADHD is an important starting point in management. The more patients and their families know about the disorder and how it affects them, the better equipped they will be to devise and implement management strategies that target their desired goals.4

COGNITIVE BEHAVIORAL THERAPY

This skills-based approach can help patients change maladaptive behaviors and thought patterns that interfere with daily functioning. Preliminary data support the efficacy of cognitive behavioral therapy as an adjunct to medication in adults with ADHD.4,6,7

Cognitive behavioral therapy for adults with ADHD4

As the name implies, cognitive behavioral therapy joins together cognitive and behavioral therapies as a management approach.

  • Cognitive Therapy

    Centers on the premise that how a person interprets an event is more important than the actual event. Treatment focuses on thoughts rather than overt behaviors, with the goal of reducing dysfunctional thoughts as a means to improve adjustment.

  • Behavioral Therapy

    Emphasizes the role of basic learning principles (eg, observational learning) in developing and maintaining behavior, both adaptive and maladaptive. Focuses on the stimuli and conditions that maintain maladaptive behaviors, rather than the thoughts driving these behaviors.

  • Cognitive Behavioral Therapy

    Blends these 2 therapeutic approaches based on 3 core beliefs:

    • Cognitive activity affects behavior
    • Cognitive activity can be monitored and modified
    • Behavioral change can be produced by cognitive change

Evidence for effectiveness of cognitive behavioral therapy in adults with ADHD2,4

The literature on cognitive behavioral therapy in ADHD suggests that patients with ADHD who receive this form of psychological treatment may attain symptom improvement when added to pharmacotherapy.

In a study involving patients with ADHD already receiving ADHD medication treatment, those individuals randomly assigned to also receive cognitive behavioral therapy reported significant reductions in the core symptoms of ADHD (ie, inattention, hyperactivity, impulsivity) both at the end of treatment and at the end of follow-up 3 months later.

The cognitive behavioral therapy program applied in this study included the following 5 components:

  • Neurocognitive skills:

    learning strategies to improve attentional control, memory, impulse control, and planning

  • Problem solving:

    developing skilled thinking, problem identification, consequential thinking, managing conflict, and making choices

  • Emotional control:

    managing feelings of anger and anxiety

  • Pro-social skills:

    recognizing the thoughts and feelings of others, empathy, negotiation skills, and conflict resolution

  • Critical reasoning:

    evaluating options and developing effective behavioral skills

COACHING/SKILLS TRAINING

ADHD coaches can help adults learn practical life skills to manage the daily challenges of the disorder (eg, being disorganized, forgetful, tardy).3-5

ADHD coaching6

ADHD coaching is an emerging field that seeks to address the daily challenges of living with the disorder. An ADHD coach helps patients learn how to manage the basics of daily life (eg, keeping appointments) in an organized, goal-oriented, and timely fashion. A coach accomplishes this by teaching patients practical life skills and ways to initiate change in their daily lives.

Coaches provide encouragement, recommendations, and feedback and teach practical techniques, such as reminders, questions, and calendar monitoring. Through individualized support, coaches help patients focus on where they are now, where they want to be, and how they can get there.

Skills a patient may acquire through coaching6

  • Some of the life skills a patient may acquire through ADHD coaching include:

    • How to maintain focus to achieve desired goals
    • How to translate abstract goals into concrete actions
    • How to build motivation and use rewards effectively

Regular meetings—either in person, by phone, or by e-mail—are an essential part of the ADHD coaching process. Interaction enables the coach to learn how ADHD symptoms influence the daily life of the patient, enabling the coach to tailor his or her encouragement, recommendations, feedback, and practical techniques to address specific challenges faced by the patient.

Patients most likely to benefit from coaching5,6

Research suggests that ADHD coaching may be beneficial for adults and possibly some teens with the disorder.5 Patients may benefit from coaching when they are able to commit to the process and are able to admit they have a problem. Patients also benefit when they spend the time necessary to create strategies for improving their behavior and can adhere to those strategies to the best of their ability.

A caveat about ADHD coaching6

Patients who are considering coaching should be informed of the following caveat: Coaching is not therapy. Coaches address the challenges of daily life—they focus on what, when, and how, not why. They are not trained to address psychiatric, emotional, or interpersonal challenges; these issues fall under the purview of mental health professionals.

MANAGING ADHD AT WORK

The symptoms of ADHD can present many challenges for an adult in the workplace, just as they may for a child in school. Although each adult patient’s challenges are unique, some general strategies may be helpful to adults with ADHD when applied at work.9

  • Workplace accommodations

    A very helpful, but sometimes overlooked, intervention involves reasonable accommodations in the workplace setting.

  • Take steps to decrease distractibility

    The patient may consider requesting a private office or quiet cubicle, or he or she may find it helpful to take work home or work when others are not in the office. Another key strategy is to perform only one task at a time; another task should not be started until the current one is done.

  • Learn how to limit impulsivity

    Adults with ADHD who struggle with impulsivity in the workplace may benefit from learning how to anticipate problems that regularly trigger impulsive reactions and develop routines for coping with these situations. Practicing relaxation and meditation techniques may also help.

  • Channel hyperactivity

    A patient with ADHD may find it helpful to take intermittent breaks to move around, exercise, or take a walk. During meetings, taking notes may help to prevent restlessness.

  • Outsmart a poor memory

    To counteract forgetfulness, adults with ADHD can try writing checklists for complicated tasks; using a day planner, smart phone, or other PDA device to keep track of tasks and events; setting up reminder announcements on the computer; and writing notes on sticky pads and putting them in highly visible places.

  • Avoid the opportunity for procrastination

    Having a firm deadline in place can help prevent a patient from continuously delaying completion of a project. Tasks can be broken into smaller pieces, with small rewards along the way (eg, a walk to the coffee shop). The patient may also want to consider working on a team with a coworker who manages time well.

Not all interventions are appropriate for all patients.

References:

  1. Asherson P, Buitelaar J, Faraone SV, Rohde LA. Adult attention-deficit hyperactivity disorder: key conceptual issues. Lancet Psychiatry. 2016;3:568-578.
  2. Post RE, Kurlansik SL. Diagnosis and management of attention-deficity/hyperactivity disorder in adults. Am Fam Physician. 2012;85(9):890-896.
  3. Kubik JA. Efficacy of ADHD coaching for adults with ADHD. J Atten Disord. 2010;13(5):442-453.
  4. Murphy K. Psychosocial treatments for ADHD in teens and adults: a practice-friendly review. J Clin Psychol. 2005;61(5):607-619.
  5. Children and Adults with Attention-Deficit/Hyperactivity Disorder. ADHD coaching for adults. help4adhd website. http://www.chadd.org/Portals/0/Content/CHADD/NRC/Factsheets/coaching-adults.pdf. Published 2015. Accessed June 28, 2018.
  6. Emilsson B, Gudjonsson G, Sigurdsson JF, et al. Cognitive behaviour therapy in medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. BMC Psychiatry. 2011;11:116. doi:10.1186/1471-244X-11-116.
  7. Antshel KM, Hargrave TM, Simonescu M, et al. Advances in understanding and treating ADHD. BMC Med. 2011;9:72. doi:10.1186/1741-7015-9-72.
  8. Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921.
  9. Children and Adults with Attention-Deficit/Hyperactivity Disorder. Succeeding in the workplace. help4adhd website. http://209.126.179.230/documents/WWK16.pdf. Published 2003. Accessed June 28, 2018.