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Psycho education is an integral part of the coaching process. It is during this phase of the coaching relationship that the coach educates the client about how and where the challenges of AD/HD are manifested in their life. The knowledgeable, well-trained certified AD/HD coach, from an accredited program, understands the ADHD brain and has the knowledge, language to clearly explain the bio-neurological nature of AD/HD. The coach conveys the invisible executive function challenges of ADHD in models, metaphors, stimulating language that attracts the attention of their client and significantly improves their understanding of their own type of ADHD.

Diagnosticians and physicians often do not have the time explain ADHD to their patients in ways they will understand so they leave their offices with a diagnosis they don’t understand. The diagnosis they are given makes them feel blind to what they have and how it manifests in their world. Coaches are trained to explain in simple, descriptive language how the invisible challenges of ADHD can be made more visible, to their clients, so they can learn to identify the specific situations, tasks and environments which could impede their ability to activate their brains and gain momentum with accomplishing an important goal or task.

For example, some people who have AD/HD tend to be visual processors and can sustain their focus by seeing or thinking in pictures. To improve the understanding of how and where AD/HD manifests, the coach will communicate with creative metaphors, models and language to support their clients with visualizing how AD/HD affects their life and how it can be managed.

The coach may describe the brain as an engine of a car which needs the “fuel of interest” to ignite it and the prefrontal cortex as the steering wheel which allows the driver to choose a positive intention or direction for the car to move towards their desired destination. The client can learn how stepping on the brain’s brakes, when the client feels disharmony in his body, allows him to pause and pay attention to what they are paying attention to and identify the emotion they are feeling in the moment.

By pausing to name the negative emotion, they are diminishing its impact. Without the pause, the dominant, unnamed emotion can lead to ruminative cycle of thinking which can impede any forward momentum. The skill of identifying a negative emotion in the moment, such as anger, frustration, sadness, anxiety, hopelessness, etc.is the foundation for learning the skill of emotional intelligence and is essential for improving emotional self-regulation. Rather than keeping the negative feeling repressed inside one’s body which can create negative chemicals like cortisol and increases stress, the skill of emotional intelligence improves self-regulation and can prevent the client from making impulsive decisions which can have dire consequences.

During the psycho education phase of coaching, the AD/HD coach shares information supported by scientific research about AD/HD. The credibility of this documented and proven body of knowledge from reputable and respected sources, such as health care institutions, organizations and other authorities on AD/HD illustrates and explains the client’s past inability to perform as a function of undiagnosed and untreated AD/HD, not because of being “broken” or having had a character flaw.

Understanding how AD/HD affects the brain and the life of an individual diminishes, and in many cases, eliminates years of self-blaming behaviors that have contributed to the low self-perception of the individual who has AD/HD and a continued cycle of failure.

If the client is to have a greater understanding and awareness of their ADHD challenges as behaviors of a bio-neurological brain wiring, which in certain situations is challenged, but in other situations can lead to success (situational variability), they can begin the process of accepting, understanding the specific situations, tasks where they can consistently experience success. The coach can then work with their clients to integrate the successful lessons learned and integrate them, more frequently, into their daily life.

Resources:

Thomas E. Brown, A New Understanding of ADHD in Children and Adults, Executive Function Impairments (New York, Rutledge, 2013)

Russell Barkley, Taking Charge of Adult ADHD (New York, The Guilford Press, 2010)

David Giwerc, Permission to Proceed: The Keys to Creating a Life of Passion, Purpose and Possibility (Albany New York, ADD Coach Academy Press, Vervante, 2011)

Kristin Neff, Self-Compassion, Stop Beating Yourself Up and Leave Insecurity Behind (New York, HarperCollins Publsihers,2011)

Travis Bradberry & Jean Graves, Emotional Intelligence 2.0 (San Diego, TalentSmart,2009)

http://medicalwritingtraining.com/Cognitive Behavioral Therapy (CBT) is a one to one therapy, for adolescents or adults, where a therapist teaches an ADHD patient how thoughts, feelings, and behaviors are all interrelated and how each of these elements affects the others. CBT emphasizes cognition, or thinking, because a major goal of this therapy is to help patients identifying thinking patterns that lead to problem behaviors. For example, the therapist might discover that the patient frequently has negative automatic thoughts such as “I’m stupid” in challenging situations. We call the though ‘automatic’ because it invades the patients consciousness without any effort. Thinking “I’m stupid” can cause anxiety and depression which leads to failure. Thus, stopping the automatic thought will modify this chain of events and, hopefully, improve the outcome from failure to success.

CBT also educates patients about their ADHD and how it affects them in important daily activities. For example, most ADHD patients need help with activity scheduling, socializing, organizing their workspace and controlling their distractibility. By teaching specific cognitive and behavioral skills, the therapist helps the patient deal with their ADHD symptoms in a productive manner. For example, some ADHD patients are very impulsive when conversing with others. They don’t wait their turn during conversations and may blurt out irrelevant idea. This can be annoying to others, especially in the context of school or business relationships. The CBT therapist helps the patient identify these behaviors and creates strategies for avoiding them.

So, does CBT work for ADHD? The evidence base is small, but when CBT has been used for adult ADHD, it has produced positive results in well-designed studies. These studies typically compare patients taking ADHD medications with those taking ADHD medications and receiving CBT. So for now, it is best to consider CBT as an adjunct to rather than a replacement for medication. There are even fewer studies of CBT for adolescents for ADHD. These initial studies also suggest that CBT will be useful for adolescents with ADHD who are also taking ADHD medications. Some data suggest that CBT can be successfully applied in the classroom environment but, again, the evidence base is very small.

How can this information be used by doctors and patients for treatment planning? Current treatment guidelines suggest starting with an ADHD medication. After a suitable medication and dose is found, the patient and doctor should determine if any problems remain. If so, than CBT should be considered as an adjunct to ADHD medications.
 

References:
Antshel, K. M. & Olszewski, A. K. (2014). Cognitive Behavioral Therapy for Adolescents with ADHD. Child Adolesc Psychiatr Clin N Am 23, 825-842.
Safren, S. A., Sprich, S., Mimiaga, M. J., Surman, C., Knouse, L., Groves, M. & Otto, M. W. (2010). Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA 304, 875-80.
Solanto, M. V., Marks, D. J., Wasserstein, J., Mitchell, K., Abikoff, H., Alvir, J. M. & Kofman, M. D. (2010). Efficacy of meta-cognitive therapy for adult ADHD. Am J Psychiatry 167, 958-68.

http://medicalwritingtraining.com/The term “cognitive behavior therapy (CBT)” refers to a type of talk therapy that seeks to change the way patients think about themselves, their disorder and the world around them in a manner that will help them overcome symptoms and achieve life goals. Because CBT is typically administered by a psychologist or other mental health professionals, CBT services are not available in primary care. Nonetheless, it is useful for primary care practitioners to know about CBT so that they can refer appropriately as needed. So, what can we say about the efficacy of CBT for treating adults with ADHD. Based on a meta-analysis by Young and colleagues, we know for certain that the number of published trials of CBT for adult ADHD is small; only nine trials are available. Five of these compared CBT with waiting list controls; three compared CBT with appropriate placebo control groups. In all of these studies, patients in the CBT and control groups were also being treated with ADHD medications. Thus, they speak to the efficacy of CBT when given as an adjunctive treatment. The meta-analysis examined the waiting list controlled studies and the placebo controlled studies separately. For both types of study, the effect of CBT in reducing ADHD symptoms was statistically significant, with a standardized mean effect size of 0.4. This effect size, albeit modest, is large enough to conclude that CBT will be useful for some patients being treated with ADHD medications. Given these results, a reasonable guideline would be to refer adults with ADHD to a CBT therapist if they are being maintained on an ADHD medication but that medication is not leading to a complete remission of their symptoms and impairments. So listen to your patients. If, while on an appropriately titrated medication regime, they still complain about unresolved symptoms or impairments you need to take action. In some cases, changing their dose or shifting to another medication will be useful. If such approaches fail or are not feasible, you should consider referral to a CBT therapist.
 

REFERENCE
Young, Z., Moghaddam, N. & Tickle, A. (2016). The Efficacy of Cognitive Behavioral Therapy for Adults With ADHD: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Atten Disord.

Joseph Biederman AIA rX8AEq
This blog addresses the relationship between executive function deficits in general and working memory (WM) deficits in particular and attention-deficit/hyperactivity disorder (ADHD). 

Although some neuropsychological models of ADHD have proposed that ADHD arises from deficits in executive functions, accumulating clinical evidence show that it afflicts some but not all individuals with ADHD and suggests that ADHD and executive function deficits represent separate clinical conditions.

Because executive functions refer to a wide and diverse group of high order mental functions, one approach to evaluate this important issue is to focus on one prominent facet of executive functions, mainly working memory. Working memory (WM) refers to a key brain system that provides temporary storage and manipulation of information essential for adequate cognitive functioning.  It focuses attention, inhibits irrelevant stimuli, recognizes priority patterns and hierarchies and selects the goals that are best suited to solving a problem.

Since these cognitive processes are critical for learning, their impairment can lead to deficits in functioning including social and educational dysfunction, low educational achievement and can have a serious impact on educational success. 

To address this issue we examined referred youth with and without ADHD, and with and without WM deficits in functional, social and academic outcomes. We used Resting State FMRI imaging to examine whether the neural circuits subserving WM deficits overlap with those of ADHD.  We investigated this issue in preclinical studies where we examined spatial WM and dopamine receptor activity in rodents.  Our preclinical findings demonstrate that the magnitude of improvement in WM produced by the D4 receptor agonist is significantly greater than that produced by methylphenidate.

CBT treats Executive Dysfunction Free ADHD CME WyUaeE
In human studies, we examined whether the most standard treatment for ADHD has a different effect on measures of WM and ADHD. This body of research provides evidence for a clinical, pharmacological and neurobiological dissociation between ADHD and WM deficits.  Our human treatment study with methylphenidate provided evidence for very different effects for ADHD and WM deficits Our clinical studies show that significantly more youth with ADHD had WM deficits than controls (31.9% vs. 13.7%) and their presence is significantly and specifically associated with academic failure.

In our imaging study, we found that brain activations to a WM test were different in subjects with ADHD with associated WM deficits compared to controls and ADHD subjects without WM deficits.

This body of work indicates that WM deficits afflict a minority of subjects with ADHD and when present they significantly and selectively increase the risk for academic dysfunction in subjects with ADHD, they have separate neural underpinning, and respond differently to treatments for ADHD.

Screening for WM deficits may help identify individuals with ADHD at high risk for academic dysfunction.

 

References

P. LEE, N. PINEDA, T. BRUNE, K. PATEL, A. GANNON, T. J. SPENCER, J. BIEDERMAN, P. G. BHIDE, J. ZHU. Hyperactivity and working memory deficits induced by prenatal nicotine exposure are associated with dopamine D1 and D4 receptor dysfunction. Society for Neuroscience Annual Meeting, Washington, DC, November, 2014

Fried R, Chan J, Feinberg L, Pope A, Woodworth KY, Faraone SV, et al. Clinical correlates of working memory deficits in youth with and without ADHD: A controlled study. Journal of clinical and experimental neuropsychology. 2016;38(5):487-96.

Mattfeld AT, Whitfield-Gabrieli S, Biederman J, Spencer T, Brown A, Fried R, et al. Dissociation of working memory impairments and attention-deficit/hyperactivity disorder in the brain. NeuroImage Clinical. 2016;10:274-82.

Biederman J, Chan J, Spencer TJ, Woodworth KY, Kenworthy T, Fried R, Bhide P, Faraone SV. Evidence of a pharmacological dissociation between the robust effects of methylphenidate on ADHD symptoms and weaker effects on working memory. Journal of Brain Sciences. 2015; 1(2): 43-53.

 

 

 

David Giwerc ADHD in Adults 2KdZ7t
ADHD Coaching an Integral Component of Effective Comprehensive Treatment for Adults with ADHD

Research clearly indicates psychopharmacology’s prominent role as an ADHD intervention.

Even if the primary care physician is comfortable with treating an ADHD adult, the typical office visit does not allow sufficient time to address every issue that confronts the newly diagnosed adult ADHD patient. The patient may leave with an appropriate ADHD medication regimen, but many other critical problems related to the diagnosis may remain unaddressed.

Medications can significantly improve focus while reducing other symptoms of ADHD. However, ADHD medications alone cannot teach the patient how to compensate for life skills that were never learned due to the years of executive function impairment.

ADHD coaching builds a bridge between biology and behavior and narrows the gap between ability and performance. Patients and physicians are beginning to realize the importance of including an ADHD coach as part of the treatment team. Just as an athletic coach motivates an athlete, ADHD coaches are very adept at motivating their clients who have ADHD, while partnering with them to develop and practice newly learned personal, social, and professional skills. For some patients, these skills may not have been developed due to lack of ADHD education, proper diagnosis, and treatment.

CBT_treats_Executive_Dysfunction_Free_ADHD_CME_CJkZtu.png.jpgThe stigma surrounding ADHD as nothing more than an “unruly child syndrome,” coupled with the popularity of incorrectly self-diagnosing an ADHD impairment, means too many patients are conditioned not to speak up and not to seek support, especially in the workplace. Adult ADHD coaching clients have often stated that an ADHD coach was the first person to not only understand the frustration of their invisible challenges, but also to sincerely believe all of their ADHD stories.

Physicians can rarely provide the level of attention and encouragement an adult patient needs within the restrictions of the typical office visit. The coach, therefore, can reinforce their patients’ natural talents and successes. The PAAC* or ICF**-certified ADHD coach can create an environment that encourages open communication (necessary for behavioral changes to occur) and forms a foundation of unconditional acceptance. Coupled with science-based instruction about ADHD, the coach focuses on identifying the patient’s natural talents and successes and develops a plan to convert that into daily strengths.

ADHD coaches help the client develop coping strategies, a valuable adjunct to medication management. They are highly specialized professionals, well-versed in ADHD-specific coaching competencies. The coach provides psycho-educational support, improves self-awareness of how symptoms of ADHD, and helps translate that into improved short and long-term performance.

While coaching cannot replace stimulant medications or therapy as a treatment, a coach can provide customized strategies and education that work alongside medication. The ADHD coach may suggest lifestyle changes such as proper sleep, nutrition, physical activity, and breathing exercises. In addition, ADHD coaching is accessible, with most coaching being conducted via phone/Skype, eliminating the need for geographical proximity or disruption to the work day.

*PAAC: Professional Association of ADHD Coaches, (PAAC)

**ICF: International Coach Federation

Cardiovascular Safety of ADHD Medications - ADHD in Adults

Resources:

Lidia Zylowska, The Mindfulness Prescription for Adult ADHD (Boston, Trumpeter, 2012)

Thomas E. Brown, A New Understanding of ADHD in Children and Adults, Executive Function Impairments (New York, Rutledge, 2013)

David Giwerc, Permission to Proceed: The Keys to Creating a Life of Passion, Purpose and Possibility (Albany New York, ADD Coach Academy Press, 2011)

John Ratey, Spark Revolutionary New Science of Exercise & the Brain (New York, Little, Brown & Co. 2008)

http://medicalwritingtraining.com/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.

 
REFERENCES
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.)

Stephen_Faraone_PhD_ADHD_in_AdultsIt sounds like science fiction, but scientists have been testing computerized methods to train the brains of ADHD people with the goal of reducing both ADHD symptoms and cognitive deficits such as difficulties with memory or attention.   Two main approaches have been used: cognitive training and neurofeedback.  This of course is in addition to, not a replacement for, ADHD medications.

Cognitive training methods ask patients to practice tasks aimed at teaching specific skills such as retaining information in memory or inhibiting impulsive responses.  Currently, results from ADHD brain studies suggests that the ADHD brain is not very different from the non-ADHD brain, but that ADHD leads to small differences in the structure, organization and functioning of the brain.  CBT_rubricThe idea behind cognitive training is that the brain can be reorganized to accomplish tasks through a structured learning process.  Cognitive retraining helps people who have suffered brain damage, so was logical to think it might help the types of brain differences seen in ADHD people.  Several software packages have been created  to deliver cognitive training sessions to ADHD people.  You can read more about these methods here: Sonuga-Barke, E., D. Brandeis, et al. (2014). “Computer-based cognitive training for ADHD: a review of current evidence.” Child Adolesc Psychiatr Clin N Am 23(4): 807-824.

Neurofeedback was applied to ADHD after it had been observed, in many studies, that people with ADHD have unusual brain waves as measured by the electroencephalogram (EEG).  We believe that these unusual brain waves are caused by the different way that the ADHD brain processes information. 

Because these differences lead to problems with memory, attention, inhibiting responses and other areas of cognition and behavior, it was believed that normalizing the brain waves might reduce ADHD symptoms.  In a neurofeedback session, patients sit with a computer that reads their brain waves via wires connected to their head.  The patient is asked to do a task on the computer that is known to produce a specific type of brain wave.   The computer gives feedback via sound or a visual on the computer screen that tells the patient how ‘normal’ their brain waves are.  By modifying their behavior, patients learn to change their brain waves.  The method is called neurofeedback because it gives patients direct feedback about how their brains are processing information.

Both cognitive training and neurofeedback have been extensively studied.  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 many rigorous studies have been conducted and summarized with a sophisticated mathematical method.   Although both cognitive training and neurofeedback are rational methods based on good science, meta-analyses suggest that they are not helpful for reducing ADHD symptoms.  They may be helpful for specific problems such as problems with memory, but more work is needed to be certain if that is true.

The future may bring better news about these methods if they are modified and become more effective.  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.

As a reminder, adult ADHD tests can be administered easily and effectively to measure the effect of various approaches on ADHD symptoms in adults.

Cognitive Behavioral Therapy treats Executive Dysfunction