ADHD “is a lifelong condition that doesn’t go away, so managing it is a lifelong responsibility”; however, this doesn’t mean that individuals will need medication or therapy forever, Jaksa said. “There are millions of people with ADHD living productive, happy lives who have learned how to manage it well and no longer need professional treatment, or only need treatment for a brief time to deal with challenging life changes,” he said.
Traditional talk therapies that focus on insight and support are ineffective for ADHD. The best approach is for therapists to use evidence-based manuals, which research has shown are effective—like CBT—and adapt them to individual cases, Robin said. “The therapy needs to be more behavioral, practical, and goal-directed,” Jaksa said.
CBT targets maladaptive thoughts and behaviors. A therapist helps individuals move from “I can never be successful” to “I may have failed at some things, but I can make changes.” When procrastination is a problem, a therapist will help “develop prompts, reminders, schedules, and time management tools to accomplish major tasks,” Robin said.
You’ll work on prioritizing, problem solving and picking the best solution, said Steven A Safren, Ph.D., director of behavioral medicine at Harvard Medical School and co-author of Mastering Your Adult ADHD. “We try to make people know what they need to do. If they decide not to do it that’s a rational decision, vs. a surprise of backed-up bills, taxes, and homework,” he said. Therapy also may address low self-esteem, anxiety, and depression, as these commonly co-occur with ADHD.
The length of therapy depends on the type of patient and the presence of co-occurring conditions, which can prolong treatment. Adults seeking therapy to improve organization, time management, and defeating thoughts can see improvement in 10 to 12 sessions with CBT, Robin said. Sessions are once a week or every other week. With younger patients, therapists mainly work with parents on management strategies. Modifying behavior and improving school functioning typically takes about 10 to 15 sessions over four to six months, he said. For teens, 18 sessions is recommended, which Robin and his colleagues outline in the manual, Defiant Teens.
Common Challenges in Psychotherapy
- Teens. Adolescents usually don’t want to attend therapy, said Robin, co-author of Your Defiant Teen: 10 Steps to Resolve Conflict and Rebuild Your Relationship. They may be in denial about their diagnosis and refuse to deal with it. Instead of being confrontational, Robin finds what the teen is passionate about (e.g., sports) and discusses how ADHD may improve that interest.
- Appointments. Patients commonly forget their therapy appointments. This is why it’s important to start treatment by creating a calendar system—it facilitates therapy—which Safren’s CBT model does.
- Tasks. Individuals have difficulty completing tasks between sessions, because they simply forget. Some of Robin’s patients “take brief notes during the therapy session and clearly summarize the action steps to take before the session,” he said.
- Relationships. Patients’ significant others may misconstrue their behavior and believe the patient isn’t motivated to change, not realizing that ADHD is to blame, Robin said. Bringing your significant other to therapy can help tremendously.
Pharmacological therapy usually follows these steps:
- Selecting a medication. “Many adults will benefit from the same medications as benefit kids with ADHD,” Robin said. “Selecting medication includes gathering information about other blood relatives with the same disorder who responded well or poorly to a specific condition,” said Dr. Robb, the psychiatrist at Children’s National Medical Center. When patients take their medication depends on how ADHD impairs them, Robin said. Work with your physician to identify the purpose of your medication. Children typically take medication to improve school performance, social interactions, and impulsive behavior, he said. Some of the adults Robin works with are mostly concerned about positive interactions and “not losing their cool with their spouses and kids.” They take medication in the evenings and weekends. Other adults have difficulty focusing on work, so they take medication during the day.
- Starting medication. The doctor prescribes medication at its lowest dose to minimize side effects “titrated up to a target and/or maximum dose until ADHD symptoms improve or side effects become troublesome,” Dr. Robb said.
- Seeing improvement. Two-thirds of individuals starting on a stimulant will experience a “good result” with the first medication, she said. You’ll typically notice an improvement in attention and concentration and reductions in hyperactivity, physical restlessness, impulsivity, and “activation difficulties”—easier-to-start tasks patients usually avoid, Jaksa said. Of individuals starting Strattera, three-fifths will have a good result, Dr. Robb said.
For information on medication in children, check out this parent-friendly guide.
Concerns about Medication
People have various concerns about medication, including worries that it leads to dependence and substance abuse, can stunt growth and increase the risk for suicide and cardiovascular problems.
“If the person is taking the right medication, at the right dosage level for him or her, the side effects of stimulants tend to be pretty mild – some appetite loss, maybe trouble falling asleep, and some increase in blood pressure for some individuals,” Jaksa said.
According to research and clinical experience, when stimulant medication is taken properly, it isn’t physically addictive, he said. In fact, “People with ADHD who are properly medicated have less substance abuse, and less risk for future abuse, than those who are not medicated,” Jaksa said. He added that ADHD medications will not stunt a child’s growth as long as the child is receiving proper nutrition.
If patients are taking medications that increase the risk for suicide, they “should be monitored for those thoughts,” Dr. Robb said. Before medication is started, the physician should obtain a familial history of “cardiovascular risks, including fainting episodes and change in exercise tolerance,” she said. If taking stimulants, adults with heart disease or high blood pressure “should be followed closely by their cardiologist/internist.”
Tips for taking medication safely and effectively include:
- Take it consistently.
- Never adjust the dose without medical supervision.
- Communicate with your doctor.
- Disclose if you’re taking any “vitamin/herbal supplements, over-the-counter medications and prescription medications, and if you’ve developed a new medical condition (e.g., asthma),” Dr. Robb said.
- Make medication part of your daily routine (e.g., take it after breakfast), Jaksa said. Use reminders: Carry a pill box, set the alarm on your watch or have backup medication at school or work, Safren said.
- Avoid alcohol and illicit drugs.