Dr Robert London

Approaches, Perspectives on ADHD

Clinical Psychiatry News - Volume 32, Issue 6, Page 28 (June 2004)

Twenty-five years ago, a gentleman was referred to me with chief complaints of poor concentration, forgetfulness, and feelings of failure.

He was a real estate broker, and when deals were being made, he said he would often focus on a “fly on the ceiling.” As a result, he missed certain points and even lost clients because he was not paying full attention. He would remember to buy birthday cards for family, friends, and clients and then forget to mail them. He would then get frustrated and angry over his failures.

Lateness and procrastination also were problems for him. As he was getting ready to leave home to meet a client, he might start repairing a broken venetian blind and end up arriving late for the meeting. Lost car keys were another problem. As he became more frustrated and unhappy, low self-esteem and despair dominated his life.

The patient was treated for depression with a tricycle antidepressant, which had no therapeutic value but did have side effects. Then he tried explorative psychotherapy. He gained insight into unhappy periods in his life, but that had no positive effect on the current disruptions.

It was clear that, while growing up, he had experienced problems at school. He couldn't sit still, he had poor concentration, and his grades were bad. He would forget to bring home his assignments, so his homework assignments were rarely done. What was going on?

We all know the answer: He suffered from one or more of the forms of what we now call attention-deficit hyperactivity disorder (ADHD).

But 25 years ago, the attention-deficit concept was new. In this case, long before that, the parents had been told that their son had minimal brain dysfunction (MBD), a diagnostic label still seen in textbooks as late as the early 1980s (“Modern Synopsis of Comprehensive Textbook of Psychiatry,” Baltimore: William & Wilkins, 1981, p. 875). Sometimes the concept of a “brain-injured child” was used in place of MBD. The imagery of MBD was that of a brain full of holes—like Swiss cheese. Such diagnostic labels and imagery devastated parents. Where was the brain damage, and was it going to get worse? The thinking at the time was that there was some good news: At age 18, the problems went away.

They did not go away. I remember being taught about MBD early in my career. No data were available to show that it went away, but those teaching psychiatry of that era “knew” it was so, even though we saw patients who had a diagnosis of MBD as children and were still suffering some of the same symptoms as adults.

Why weren't the psychiatrists able to gather the information about a changing syndrome?

Once we recognized that my patient's attention-deficit problem had continued into his adult life in an altered form, we began to make progress. The psychotherapy was educational, mainly focusing on relearning and rethinking, and leading into cognitive restructuring.

ADHD has a profound effect on emotions, so the psychotherapeutic approach is twofold: Address the emotional problem stemming from adult ADHD and teach new cognitive skills that focus on the everyday situations that this disorder produces. We evaluated poor concentration, distractibility, lateness, procrastination, forgetfulness, frustration and anger, and decreased self-esteem.

Neither methylphenidate nor the amphetamines were used in the adult population at the time, so talk psychotherapy was the method of choice. Actually, I believe that many ADHD problems in adults can be treated with restructuring or with educational cognitive therapy. Medications play a major role in helping this disorder, but talk therapy is essential.

The talk therapies with this patient factored in his poor concentration, lateness and procrastination, anger, frustration, and despair. They also developed a therapeutic thrust aimed at the attention deficit, or as I have always liked to call it, attention deregulation.

The following approach was taken with this patient:

  • Discuss structure and organization skills for family and business events. List making is essential.
  • Set priorities for daily activities. This is critical. At first, focus on only two important jobs per day. When things get complicated in a business situation, for example, focus on one job per day.
  • Discuss distraction and how to avoid the “fly on the ceiling” problem. The moment in which distraction takes place, it is interpreted as a negative experience and is stopped in a behavior-modification format:

1.Distraction leads to failure.

2.Failure leads to frustration.

3.Frustration leads to anger.

When my patient got the idea to fix a venetian blind before leaving home, the specifics were cognitively restructured so that the moment he started, he would stop because he was aware of what was happening.

In addition, the lateness was better controlled and avoided. Birthday cards were mailed immediately after the purchase, in one activity. Using a special hook for car keys at home and at work became a simple way to keep track of them.

These restructuring/relearning techniques work. Cognitive restructuring is effective for adults. If the psychotherapeutic community knew more about auditory and visual sequencing, and auditory and visual memory deficits as central nervous system problems, it could devise more specific cognitive therapies. Treatment approaches would then become more codified.

Medication is always an option in combination with the talk therapies. It is important to know that there are many CNS deregulations in addition to ADHD. These deregulations create a diversity of mental functioning that is not necessarily pathologic. Labels with negative connotations and meanings based on limited knowledge can create a negative therapeutic environment, which leads to poor treatments.

With children and adolescents, many psychiatrists just give medication, as do pediatricians and family physicians. It's as if they were using antibiotics for an infection that will be gone in 5 days. This is bad medical practice.

As I see it, the complicated disorder of ADHD—clearly a psychiatric/psychological problem—should be treated medicinally only by psychiatrists. We have the expertise, the time, and the resources to do it the right way.

Parents who think their children have ADHD need to be taught by us that having their child cared for by a psychiatrist is not a stigma. In other words, those parents should not be requesting that their children be treated by pediatricians or family physicians. How many psychiatrists treat infectious mononucleosis? The answer is clear.

If the children and adolescents had talk therapies, many of the adult adjustment problems might be avoided or substantially reduced.

This patient did well after a year and a half of talk therapy. With current restructuring/relearning techniques, these programs can be done in 12 weeks. After treatment, reinforcement sessions twice a year are valuable.

Ten years after this patient and I terminated, I met him accidentally on a Saturday evening while he was standing in the front of a movie theater line and I was racing to get on the end. He stopped me and said, “Hey Doc, I got here early.”

Please feel free to write me at cpnews@elsevier.com, and let me know about strategies you have used. I will try to pass them on to my readers.

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