ADHD and Psychotherapy
Dr Jonathan Haverkampf
Attention deficit hyperactivity disorder (ADHD) is one of the psychiatric conditions where psychotherapy has for long been underappreciated. Its diagnosis and treatment have been controversial since the 1970s, and it is still not entirely clear whether ADHD is predominantly a genetic condition, or even whether it is a distinct disorder at all. To this one can add controversies around the use of stimulant medications in children and adults and the method of diagnosis. Some sociologists even go so far to regard ADHD as an example of the medicalization of poor school performance or otherwise behaviour which deviates from general expectations. The most likely cause of ADHD is, as in many other disorders affecting the brain, an interaction of genetics and the environment.
The importance of the quality of a child’s interactions with his or her and environment in the development of ADHD is also the reason why psychotherapy has potentially such an important role to play in its treatment. If counselling improves an individual’s communication with the environment and oneself, it can be an effective tool in the treatment of ADHD. Helping the child’s internal communication with itself builds self-confidence and self-esteem which are effective defences against the problematic interaction patterns that maintain ADHD.
ADHD is estimated to affect, depending on the study, from 1% to 7% of people aged 18 and under. The symptoms usually begin by age six to twelve. Inattention, hyperactivity in children and restlessness in adults, disruptive behaviour, and impulsivity are common hallmarks of ADHD. Difficulties in academic pursuits, at the workplace and in relationships often cause great suffering in adults and isolate the person suffering from ADHD even more. Less than 5% of individuals with ADHD in the US get a college degree.
At its most basic, ADHD is characterized by
- problems paying attention and
- excessive activity or difficulty controlling behaviour inappropriate to one’s age.
In children, problems paying attention may result in poor school performance, but if a child is very interested in an activity, the performance may not be impaired. Motivation plays an important role in ADHD and this is also why psychotherapy which engages a client in meaningful and motivating communication can help ameliorate the negative effects of ADHD in a client’s life.
Between 2–5% of adults are estimated to have ADHD, often as a continuation from childhood ADHD. Most remain untreated. In adults there are more likely to be feelings of restlessness and constant mental activity, as well as mood swings, and irritability. This may go hand in hand with low mood and poor self-image as well as depression and anxiety. Adults with ADHD may experience an inability to relax or talk without end in social situations. Many adults diagnosed with ADHD have a disorganized life and frequently use alcohol or drugs to help them cope with the restlessness on the inside and the chaotic lifestyle on the outside.
Adults with ADHD quite frequently have relationship and job difficulties. They may start a relationship on an impulse and describe themselves frequently as short-tempered. The impulsiveness and the restlessness can lead to gambling and risky sexual practices. The unrewarding social interactions and unfulfilling relationships lead to even more social isolation and a seemingly self-inflicted withdrawal from society, which makes the symptoms of ADHD even worse. Often only new and better interactions with other people, such as the ones learned in a counselling session, can break this vicious cycle, which otherwise not infrequently leads to social isolation.
While ADHD is generally accepted as a distinct disorder in the small number of people with severe symptoms, there is an ongoing debate on how to diagnose and treat those with less severe symptoms. The problem is that ADHD is a very general description of deviating behaviour and cognition, and it is not always easy to determine where normal behaviour and cognition end and pathology begins. ADHD is diagnosed by an assessment of a person’s childhood behavioural and mental development. However, the diagnosis depends on the diagnostic manual used, which is not encouraging for clinicians and patients. With the North American DSM-IV criteria a diagnosis of ADHD is 3–4 times more likely than with the ICD-10 criteria commonly used in Europe. Some say it is overdiagnosed, while others, such as a 2014 peer-reviewed medical literature review, argue that it is underdiagnosed in adults.
The different perspectives on what is required to safely make the diagnosis ADHD has lead to the question whether ADHD was “invented and not discovered,” in the sense that society needed to find an explanation for an observed behaviour that is difficult to explain and where pinning it to a more or less well defined biological cause is impossible, a property which ADHD, however, shares with many psychiatric disorders. Even the lack of concentration could be explained as the result of a less supportive environment on an individual susceptible to ADHD. Whatever belief one holds about ADHD there are few people who would argue that ADHD is not affected by and does not affect human communication, which thereby points to psychotherapy as a pivotal instrument in the successful treatment of ADHD.
There are psychological tests that help to confirm the diagnosis of ADHD within our understanding of the disorder. In any case, the diagnosis should be made by someone who has experience with ADHD and who has an eye for the particular social interaction patterns in individuals with ADHD which cause significant suffering and social isolation. Depending on whether ADHD is of the inattentive or the hyperactive-impulsive type it may show in seemingly countless ways as the person may
- Be easily distracted, miss details, forget things, and frequently switch from one activity to another
- Have difficulty maintaining focus on one task
- Become bored with a task after only a few minutes, unless doing something enjoyable
- Have difficulty focusing attention on organizing and completing a task or learning something new
- Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
- Not seem to listen when spoken to
- Daydream, become easily confused, and move slowly
- Have difficulty processing information as quickly and accurately as others
- Struggle to follow instructions
- Have trouble understanding minute details
- Fidget and squirm in their seats
- Talk nonstop
- Dash around, touching or playing with anything and everything in sight
- Have trouble sitting still during dinner, school, doing homework, and story time
- Be constantly in motion
- Have difficulty doing quiet tasks or activities
- Be very impatient
- Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
- Have difficulty waiting for things they want or waiting their turns in games
- Often interrupt conversations or others’ activities
Symptoms of hyperactivity tend to go away with age and turn into inner restlessness in adolescents and adults, but the key attribute to really understand about ADHD lies in the social realm. People with ADHD are more likely to have problems with social skills, which show in less effective social interactions and in difficulties in the formation and maintenance of friendships. About half of children and adolescents with ADHD experience social rejection by their peers compared to 10–15% of non-ADHD children and adolescents. People with attention deficits are prone to having difficulty processing verbal and nonverbal language which can negatively affect their social interactions. They also may drift off during conversations, and miss social cues.
Causes of ADHD
The environment does seem to play a role in conjunction with a possible genetic explanation. Alcohol intake and exposure to tobacco smoke during pregnancy can cause problems with central nervous system development and has been associated with an increased risk of ADHD. Extreme premature birth, certain infections, very low birth weight and traumatic brain injury also increase the risk. Intolerances or allergies to certain foods may worsen ADHD symptoms. The evidence on artificial food dyes or preservative, however, is weak. Medical conditions such as hyperthyroidism or lead toxicity can also lead to ADHD-like symptoms.
However, social interactions do seem to play a crucial role in the development and maintenance of ADHD. Extreme neglect, abuse and social deprivation have been linked to an increased risk for ADHD. This raises the question how the environment interacts with the child (or adult) and how the child (or adult) interacts with the environment. The youngest children in a class have been found to be more likely to be diagnosed as having ADHD possibly due to their being developmentally behind their older classmates, which points to the need for an individualized approach in the work of teachers, counsellors and anyone who works with children (and adults) who may be susceptible to ADHD, but it also points to the benefit of early psychotherapeutic help.
The argument has been made that ADHD is entirely a social construct, one that seems opportune to have when there is no explanation for the behaviour observed in a child or an adult. But maybe ADHD is at least partially a product of society, one that has to do with how we interact with each other, especially if the other is a child. We know from empirical work that symptoms typical of ADHD occur more commonly in children who have experienced violence and emotional abuse.
There is another more trivial ‘cause’ for the diagnosis of ADHD which has to do with the most common medication used to treat it, namely stimulants. 8% of all United States Major League Baseball players had been diagnosed with ADHD as of 2009. Yet the increase coincided with the League’s 2006 ban on stimulants, which might just mean that the diagnosis was used to get around the ban on the use of stimulants in professional sports.
Most healthcare providers accept ADHD as a genuine disorder, and the debate in the scientific community mainly centres on how it is diagnosed and treated. Treatment of ADHD may include the following:
- psychotherapy / counselling
- medication (predominantly stimulants)
- dietary changes
- lifestyle changes
Since one social interaction ultimately influences and shapes future interactions, psychotherapy focuses on the child’s interactions and the communication structures the child or adult is embedded in. It also should give the individual the communication tools to better live and thrive in a given social environment. This helps build self-confidence and self-esteem. If a child (or an adult) can feel a greater ability in shaping his or her relationships with others, self-confidence and self-esteem are bound to be lifted and a better sense of self will develop. In individual cases this may at least be as or even more effective than medication in the long-run since the benefit of medication in the long-run is probably limited.
There is good evidence for the use of behavioural therapies in ADHD and they are the recommended first line treatment in those who have mild symptoms or are preschool-aged. But psychotherapy should go beyond behaviour and work on a cognitive and interactive level to improve the social functioning of the child or adult, taking in concepts from psychoanalytic and systemic psychotherapy. After all, it is the problems in social interactions which can worsen or even trigger a condition of ADHD, because it interferes at the level of an individual’s interpersonal relationships with others. Establishing a safe environment that is conducive to facilitating communication seems crucial. Good relationships can go a long way to fight ADHD. The most important factor in reducing later psychological problems, such as major depression, criminality, school failure, and substance use disorders is the formation of friendships with people who are not involved in delinquent activities.
Behavioural treatment may improve long-term outcomes, but it does not get rid of negative outcomes entirely. The communication aspect should be taken into account. This is why the following approaches seem helpful in conjunction with conventional cognitive behavioural therapies:
- interpersonal psychotherapy
- social skills training
- communication training
- family therapy
- school-based interventions
- behavioural peer intervention
Therapeutic groups focused on ADHD can be helpful in improving a patient’s understanding and interactions with others. ADHD support groups may also help families cope with ADHD.
The management of ADHD typically involves counselling or medication either alone or in combination. However, the opinions on medication as a support for psychotherapy diverge. Some psychotherapists believe that medication leads to quicker and more enduring results, while others are more sceptical. Interestingly, there are also national differences in treatment recommendations. Canadian and American guidelines see medication as a first-line therapy in more cases than do European guidelines.
The medications of choice are stimulants, which in many cases increase concentration, but should not be used in pre-school children. It is still unclear whether stimulants work in the long run. Looking at the short term there may be a positive effect of the stimulant methylphenidate in up to 80% of cases. It appears to improve symptoms as reported by teachers and parents.
There are a number of substances other than the classic stimulants, but there is still a lack of good empirical comparisons on the effect of the different substances. And there is still significant uncertainty about the long-term benefits of any type of medication.
Diet & Exercise
There are few studies that can show some benefit of a certain diet. A 2013 meta-analysis found less than a third of children with ADHD see some improvement in symptoms with free fatty acid supplementation or decreased eating of artificial food colouring. Iron, magnesium, iodine, zinc and omega-3 fatty acids may have an effect, but there does not seem enough information to really recommend a certain diet.
The long-term effects of regular aerobic exercise can include improvements to behaviour, as well as improved attention and better planning. It can lead to better self-esteem, better academic and classroom behaviour, improved social behaviour, and less depression and anxiety. While this is not ADHD specific, it can be of significant benefit.
The long-term effects of conventional treatment are not that great. An 8-year follow up of children diagnosed with ADHD found that they often have difficulties in adolescence, regardless of treatment or lack thereof. As mentioned conventional treatment might not even have a large long-term effect at all. The proportion of children meeting criteria for ADHD drops by about half in the three years following the diagnosis and this occurs regardless of the type and combination of treatments used.
However, treatment that changes how individuals interact and communicate with their environment can have a long-term effect because people learn to function better in their social setting and the quality of an individual’s social interactions have been shown to have an impact on the severity of ADHD and whether the condition manifests at all. This is why psychotherapy plays an underappreciated role in the treatment of ADHD.
© Dr Christian Jonathan Haverkampf
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This paper is solely a basis for academic discussion and no medical advice is given. Always consult a professional if you believe you might suffer from a medical condition. The lists of drugs have not been checked for accuracy.
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