Working Effectively with Clients with ADHDCopyright Svea VikanderMarch 14th 2015

Adults with ADHD burn brightly (I like to call the disorder 'Burning Brightly Syndrome') and will be some of the most exciting, enthusiastic clients you have. No treatment for ADHD should try to extinguish the light that burns in these people. We should not aim to break them of their behavior like wild horses to be tamed. On the contrary, ethical approaches to ADHD acknowledge the disorder and help clients to become their full selves; to eliminate behaviors and feelings that stop them from doing what they dream and/or forming lasting human connection.

Common misconceptions about ADHD:

'Only children have it.' ADHD affects 5-10% of children and the idea that it disappears in adulthood has no solid

theoretical underpinning. Only 4% of adults have been found to meet clinical criteria for ADHD, but the number has risen

as knowledge about adult ADHD has grown. Perhaps the rest have managed their symptoms well, were misdiagnosed in the first place, and/or that the diagnostic criteria (which were established from research on hyperactive boys) do not encompass the range of adult ADHD behaviors.

'It's a problem with focusing, thus only important for doing well in school.' ADHD is comprised of global symptoms, and can affect one's ability to achieve goals and form

relationships. Many people with ADHD do well in school, and suffer more upon graduation, having lost the

structure that school provides. People with ADHD are twice as likely to die prematurely, most commonly in accidents. The risk

of such death increases the later the disorder was diagnosed. People with ADHD are twice as likely to get divorced. They also have a higher mean number of

marriages. People with ADHD are at higher risk for substance abuse (self-medicating with uppers and

downers, often at the same time). 25% of adults being treated for alcohol and substance abuse meet criteria for ADHD.

'ADHD is caused by our modern world, where everyone pays attentions to screens and nobody goes outside.'

Screen-time may worsen ADHD symptoms and time spent outside in green space has been found to lessen ADHD symptoms. Neither of these correlations mean that screens cause ADHD.

ADHD has a strong genetic component, as family aggregation studies, adoption research, twin studies, and molecular genetic analyses have shown.

Physiological bases for the disorder have been established through neurochemical and neuroimaging studies; the brains of people with ADHD are different.

We don't know what, aside from genetics, causes ADHD. Childhood stress and trauma, and exposure to environmental toxins, play a role in some cases.

'Stimulants don't help ADHD'/ 'Don't give that rat poison to your child' As of 2005, over 200 controlled studies had found stimulant medication to be helpful in reducing

symptoms of inattention, distractibility, and restlessness in 50-95% of children treated. Those whose symptoms were not ameliorated were more likely to have comorbid disorders, such as depression or anxiety.

Stimulants also work for adults, and can often replace an adult's dependence on nicotine, coffee, cola, or illegal substances.

Some adults with ADHD are not responsive to stimulants; non-stimulant medications such as Wellbutrin and Strattera are often helpful in these cases.

What do I do if I think my client has ADHD? Talk to them about their symptoms. Many adults describe themselves as "lazy" for not getting

things done, or believe they "must not really care" about something if they forget it. Talk to them about adult ADHD and what you know about it. Ask what their beliefs about ADHD are. Have an open conversation about yours, and your experience working with it.

Screen them with the Adult Self-Report Scale Symptom Checklist (attached) Find a psychiatrist with training in ADHD and make a referral for assessment. Many psychiatrists

are poorly informed about adult ADHD. For example, antidepressants are ineffective at reducing ADHD symptoms, but psychiatrists are more likely to prescribe them to a woman who presents with classic adult ADHD symptoms. Pediatric psychiatrists have training in ADHD and can be helpful when adult psychiatrists are not.

The two biggest challenges of working with adults with ADHD: Attendance and Communication

Attendance. Many adults with ADHD have trouble showing up for appointments. They forget; they have chaos in their lives which prevents them from attending; and they are likely to have a comorbid mood disorder which impairs their ability to leave the house.

Communication. Conversing with an adult with ADHD can be exhausting. People with ADHD have conversational styles that can be hard to follow; for example, they often

begin speaking in the middle of a thought, giving no context. They have also been shown to have lower than average skills in reading emotion in others and picking up on conversational cues.

The skills most therapists bring to the session - supportive listening, rephrasing, allowing silence to develop, client-directed conversations - are not effective in producing positive therapeutic interactions.

Trains of thought. Ideas for people with ADHD are like a ceramic bowl thrown from a fourth-story window. The shards are everywhere. This is why people with ADHD are so creative, funny, unconventional. But also difficult to work with, because, while their train of thought is linear (people with ADHD are not, as a rule, psychotic), it moves quickly and in ways that don't always seem to make sense.

The end result of these communication difficulties is that the therapist feels exhausted and useless, and the client feels that therapy is a waste of time.

Ways that you can work with those challenges:

Attendance: Set up reminder systems for your clients. Part of providing your clients with equal access to care is

ensuring that they can actually make it to sessions to receive that care. You can set up email and text reminders with various apps, you can mark it in your calendar to call them, and you can give these tools (referral to reminder apps) to clients themselves.

Stress the importance of showing up in conversation, and stick to your no-show payment plan. Decide on a regular day and time to meet, preferably after they have some other important task to

do (like dropping their kids off at school).

Chaos: In therapy, prioritize addressing the practical aspects of the chaos in their lives first. Look at the

reasons behind their life choices only after they have achieved a measure of stability.

Comorbid mood disorders: Treat these as you would treat a regular mood disorder, but be more inclined toward medication.

ADHD is considered by some to be at its essence a dopamine deficiency. People with ADHD found to have significant lower numbers of D2 and D3 receptors - the same receptors which have been implicated in anxiety and depression.

Communication: Don't take it personally. When your client interrupts you, continues to speak even though you have

shown that you would like a turn, or negates your speech by speaking about another topic altogether, remind yourself that this is simply a reflection of the way their mind works, and not a comment on your own skills. If you feel that their conversational style is interfering with the therapeutic relationship, or affecting the client's life outside of sessions, you can talk about it in a non-shaming manner.

Be meta. Tell your client that sometimes you would like to jump into the conversation, and ask if they would be OK with you interrupting. When you do interrupt, acknowledge it. Say, "I'm going to interrupt here because I have a question" or help the client to become aware of their conversational patterns by saying, "I'm noticing that our conversation has diverged. I'm wondering if you would like to go back to X, or continue talking about Y."

Structure your sessions. The most evidence-based treatment for ADHD is the use of medication combined with CBT. Mindfulness practices as well. Anecdotal experience shows that Life Coaching tactics can be effective.

Resources:

ADD and Loving It: documentary film about thriving with ADHD, contains interviews with adults with ADHD, treatment providers (many of whom are also adults with ADHD!). http://www.snagfilms.com/films/title/add_loving_it

Delivered from Distraction by Edward Hallowell: Classic take on lifestyle changes for making the most of ADHD symptoms.

ADDitude magazine, http://www.additudemag.com/

CHADD: Children and Adults with Attention Deficit Disorder advocacy and education, support groups in most major American cities. http://www.chadd.org/