Cognitive-Behavioural Therapy for ADHD in Adolescents and Adults

A Psychological Guide to Practice

Susan Young, Jessica Bramham

• Editorial: Wiley-Blackwell
• Año: 2012
• ISBN:
  9781119943013
• Edición: 2
• Categoría: Psychology
• Categoría: Clinical Psychology

The first edition of this book introduced the Young-Bramham Programme, a pioneering approach to cognitive behavioural treatment for ADHD in adults, which was well-received by clinical and academic communities alike. Based on the latest findings in the field, the authors have expanded the second edition to incorporate treatment strategies not only for adults, but also for adolescents with ADHD.

• Updates the proven Young-Bramham Programme to be used not only with adults but also with adolescents, who are making the difficult transition from child to adult services
• New edition of an influential guide to treating ADHD beyond childhood which encompasses the recent growth in scientific knowledge of ADHD along with published treatment guidelines
• Chapter format provides a general introduction, a description of functional deficits, assessment methods, CBT solutions to the problem, and a template for group delivery

PART I

BACKGROUND AND TREATMENT

1

INTRODUCTION

This book aims to provide clinicians with a comprehensive psychological guide to practice when working with adolescents and adults with ADHD by providing cognitive behavioural therapy (CBT) to treat core symptoms of the condition and its associated problems. As ADHD is a heterogeneous disorder, each individual is likely to present with a different constellation of symptoms with a range of psychological strengths and weaknesses. For this reason, this book consists of stand-alone modules that can be delivered in individual or group format and which together form the Young-Bramham Programme. The Young-Bramham Programme provides an innovative and intensive practical approach to the presentation of ADHD using cognitive behavioural and motivational interviewing techniques, which are described in detail using case examples. Each module is presented in a separate chapter of this book and can be used independently or in conjunction with other modules.

Practitioners often report feeling underequipped to treat this client group and there remains a limited literature on psychological treatment for adolescents and adults. Up to two-thirds of ADHD children continue to suffer with symptoms into adult life, many of whom experience residual problems which warrant treatment (Young and Gudjonsson, 2008). In addition, there are many young people who do not receive a diagnosis until they are adults in spite of having presented on numerous occasions to health services (Huntley and Young, submitted; Young, Toone and Tyson, 2003). ADHD has often been missed in the past, and misdiagnosis abounds. Aside from these clinical groups, there are additionally many individuals who have symptoms that fall below the threshold for formal diagnosis, but who nevertheless may benefit from psychological treatment to address their problems and functional impairments. Thus, the Young-Bramham Programme was developed as an intervention suitable for individuals with a formal ADHD diagnosis, individuals who are in partial remission of their symptoms, and individuals who present with an undiagnosed constellation of ADHD symptoms and related problems.

A second reason for writing the book was that we have talked to our clients and listened to their life histories. They have such stories to tell and it is clear that for many the pathway is far from easy, yet over and over again we have recognized characteristics of determination, resilience, ingenuity and creativity. We interviewed some of our patients and their partners with the aim of analyzing their experience of receiving a diagnosis and treatment for ADHD in adulthood and, for their partners, their experience of supporting them through this process. After feelings of relief and a sense of hope and expectation for the future, they were disappointed with treatment as this was not a panacea. They were not ‘cured’ and core functional problems persisted associated with organization and time-management skills, procrastination and low self-esteem (Young, Bramham and Gray, 2009; Young et al., 2008). Thus our long experience in delivering psychological interventions to adolescents and adults with ADHD, together with our extensive research on the topic, led us to develop the Young-Bramham Programme to address the persisting problems that people experience regardless of whether they receive medication or not. We are not saying that this programme will fully bridge the gap and provide a ‘cure’ for adults and young people with ADHD, we are however confident that the strategies and techniques provided in the Young-Bramham Programme will provide additional and valued support.

THE COMPANION WEBSITE

The Young-Bramham Programme book is supplemented by a Companion Website, which provides practical and pragmatic exercises that allow the client to identify personal specific problems and methods to address them. Strategies which involve writing ideas down or making lists of potential consequences target difficulties in organizational skills and memory problems which are inherent in ADHD. The therapist therefore needs to maximize the opportunity to create lists and structure plans during sessions. Examples, charts, diaries, figures, diagrams and illustrations are presented in both the book and on the Companion Website (the latter in a format suitable for use in sessions) to clarify information, and/or to improve accessibility and understanding of the concepts and issues presented. The Companion Website provides psychoeducational handouts and blank copies of relevant materials introduced in the programme. It can be accessed with the password provided. The materials can be downloaded, copied and used in treatment sessions to determine, evaluate and treat specific symptoms, problems and strategies. The materials will help the therapist and the client to collaboratively tailor the Young-Bramham Programme interventions according to the clients’ specific needs.

ADHD IN ADOLESCENCE AND ADULTHOOD

ADHD is an established neurodevelopmental condition characterized by inattention, hyperactivity and impulsivity or a combination of these problems that commences in childhood and often persists into adolescence and occupational lives. There is a clear treatment pathway. It is recognized that life span conditions such as ADHD should have a planned transfer of care from child, through adolescent, to adult services as young people move from one service to another at specified age milestones (Nutt et al., 2007).

International Guidelines on ADHD

There are published international guidelines providing advice on the assessment, treatment and management of people with ADHD (NICE, 2009; Seixas, Weiss and Muller, 2011). In the United Kingdom, the National Institute of Health and Clinical Excellence (NICE) published guidelines on ADHD in 2009 and for the first time provided guidelines for ADHD across the lifespan with the requirement for adult mental health services to recognize the disorder and provide diagnostic and treatment services. The Guidelines also drew attention to the importance of psychological interventions as a first-line treatment for children, for those with mild symptoms, and as an important complementary treatment for adults with ADHD. A key priority of the Guidelines was that drug treatment for children and young people with ADHD should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions. NICE recommended that for older adolescents direct individual psychological interventions, using cognitive behavioural and social skills paradigms, may be more effective and acceptable to the young person. They recommended that active learning strategies should be used for a range of treatment targets, including social skills with peers, problem-solving, self-control, listening skills and dealing with and expressing feelings. These recommendations endorse the cognitive behavioural paradigm employed within the Young-Bramham programme that is applied to adolescents and adults.

ADHD Symptoms

The symptoms of ADHD are inattention, hyperactivity and impulsivity however ADHD is a heterogeneous disorder and there are broad individual differences as to how these symptoms present. Additionally, with maturity there is often a shift with hyperactivity and impulsivity modifying more than attentional symptoms (Marsh and Williams, 2004). Adolescents are more likely to fidget than run around aimlessly and problems with organization and time-management become more apparent. The progression of ADHD is also heterogeneous with some individuals experiencing full remission by adulthood, some partial remission and others none at all (Faraone, Biederman and Mick, 2006; Young and Gudjonsson, 2008). While some symptoms may appear to spontaneously remit with age, relative differences that are associated with significant functional impairments may remain; indeed around two-thirds of ADHD children will experience some persisting symptoms as young adults that will be associated with significant impairment (Faraone, Biederman and Mick, 2006).

Comorbidity

For young people with ADHD comorbidity is the rule rather than the exception, as up to two-thirds of ADHD children have one or more comorbid conditions, including oppositional defiant and/or conduct disorder, anxiety, depression, substance misuse, tic disorders and autistic spectrum disorders (Biederman, Newcorn and Sprich, 1991; Elia, Ambrosini and Berrettini, 2008; Goldman et al., 1998; Pliszka, 1998). Multiple presentations to health and social services have been reported by individuals who were not diagnosed until adulthood (Huntley and Young, submitted; Young, Toone and Tyson, 2003) suggesting ADHD symptoms are being missed or misdiagnosed in children. Yet for those who are identified in childhood, treatment with stimulant medication may not be fully protective as follow-up data from 208 ADHD children treated with stimulants found that 23 per cent had a psychiatric admission in adulthood (mean age of 31). Conduct problems in childhood were predictive (hazard ratio HR = 2.3) and girls had a higher risk compared with boys (HR = 2.4) (Dalsgaard et al., 2002).

While many comorbid conditions can be effectively treated by psychological interventions, we have found that therapists often feel apprehensive about intervening in the same way with clients with ADHD. This may be because they lack confidence in providing treatment for individuals who may present with high rates of comorbid psychiatric problems and additional overlapping, complicating psychosocial factors. We therefore decided to write this book to share our knowledge and provide guidance for practitioners who are working with adolescents and adults with ADHD.

Aetiology

The reason people develop ADHD is not clear and most likely involves a range of genetic, environmental and psychosocial factors (NICE, 2009). ADHD often runs in families and studies have shown that it is highly heritable (Steinhausen, 2009). Genes play an important role in brain development and a number of different genes are thought to be involved and that are linked to the dopamine and serotonin systems in the brain (Stergiakouli and Thapar, 2010). Environmental factors may also affect brain development such as smoking, drinking, and substance use during pregnancy, preterm birth, low birth weight, birth trauma and maternal depression. These factors can interact with genetic/neurological factors to increase the risk of developing ADHD. The causal link between psychosocial factors and ADHD is unclear but it seems that disruption to early attachment, social adversity and deprivation may be associated with the development of ADHD (Rutter, 2005).

Sex Differences and ADHD

In childhood more boys than girls are diagnosed with ADHD with a ratio of around four to one reported in research; by adulthood however this difference becomes much less skewed (Kessler et al., 2006). This may be due to a referral bias in childhood with more boys being referred for clinical assessment due to their greater externalizing problems. Boys are more likely to present with disruptive behaviour and conduct problems leading them to attract the notice of health and educational professionals (Biederman et al., 1999; Gaub and Carlson, 1997). In contrast, girls are more likely to present with attentional problems, internalizing problems and disruption to peer relationships (Rucklidge and Tannock, 2001; Taylor et al., 19961; Young et al., 2005a, 2005b).

By young adulthood females are more likely to engage with health services for mood and anxiety disorders and/or due to pregnancy. This more frequent engagement may also be a contributory factor to the observed sex ratio adjustment in males and females being diagnosed with ADHD. Nevertheless the early sex differences in presentation of externalizing and internalizing symptoms appear to persist as higher rates of ADHD males are reported to be engaging in antisocial or criminal behaviour (Young et al., 2011) compared with ADHD females who have higher rates of psychiatric admissions (Dalsgaard et al., 2002).

These findings endorse the provision of sex specific treatments as opposed to structured ‘one size fits all’ treatment paradigm. The Young-Bramham modules are highly suited to this approach as therapists may select interventions appropriate to the individual presentation of their female and male patients. It is particularly striking that for people with ADHD, strengths and weaknesses in coping skills may be contrary to those typically reported (i.e. females usually being more prone to using emotional coping strategies and males tending to be more adept with problem-focused strategies). Indeed female adolescents adopt a variety of ineffectual coping strategies (Young et al., 2005a). Thus it is important that the therapy addresses individual coping styles and facilitates clients to select, develop and apply functional strategies to overcome their problems.

ADHD and Intellectual Functioning

ADHD is experienced by people throughout the intellectual spectrum. This means that people with high intellectual functioning also develop ADHD. However it is often mistakenly believed that high functioning individuals cannot possibly have ADHD leading them to experience a similar struggle as their lower IQ peers in attempting to get recognition and treatment for their symptoms. Their personal histories, academic and occupational attainment may be very different and without impairment in childhood but, without a doubt, what they both share in common is that they are underperforming in their personal potential and this causes confusion and distress.

In our experience the high functioning person with ADHD is more likely to present to services for diagnosis and treatment later on in life, often in adulthood. This is because they have usually learned and applied constructive compensatory strategies, such as those outlined in the Young-Bramham Programme, to support them in their endeavours. Children with high IQs are also more likely to attend selective educational establishments that are attended by other bright children. Here, they are likely to have benefited from smaller class sizes with greater structure and less opportunity for distraction; they may have had greater opportunity for individual tuition through higher teacher to pupil ratios and/or additional input by teaching assistants. This means that they may fare comparatively well academically (but usually with some inconsistency) and problems do not become evident until much later in their occupation when they are expected to take responsibility for organizing their own work and/or leading others. For individuals who remain symptomatic, this can be the point when things breakdown. Others continue to adapt and find ways to overcome challenges by applying functional strategies. For them, a breakdown in these strategies may be precipitated by external factors in their occupation (high pressure of work and long hours), and/or because their personal resources have become diminished due to the development of physical or mental health problems and/or triggered by serious life events (such as bereavement, redundancy and divorce). Then, like a row of car...