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Are We Afraid of Adderall?

Introduction

I sometimes wonder if the treatment of ADHD didn't involve stimulants such as Ritalin or Adderall, if there would be such a fear of diagnosing Adult ADHD. Therefore, effective screening and treatment for adult ADHD are essential to provide your clients the highest level of care. As a psychiatrist specializing in adult ADHD, I have seen for over 20 years the benefit of an accurate diagnosis and effective treatment.

Many people question whether or not adult ADHD exists as a legitimate diagnosis. Indeed, many claims that ADHD is overdiagnosed and that stimulants are overprescribed. Psychiatrists are afraid of becoming one of these doctors who "overprescribe." Even though stimulants are the standard of treatment for Adult ADD, whether or not someone has ADHD should not hinge on the treatment but on the proper assessment and diagnosis.

Are some people misdiagnosed with ADHD? Sure. And many people, notoriously college students, misuse stimulants to improve their performance or energy. However, more often than not, Adult ADD is under-diagnosed and under-treated. Adult ADHD affects at least 5% of the population, and it is estimated that nearly 75% of Adults with ADHD never receive an accurate diagnosis or effective treatment. An estimated 3 percent to 5 percent of U.S. adults have ADHD. Still, only 15 percent are aware they have the disorder (Steven Reinberg, Healthday, Internet)

Dr. David L. Katz, the director of the Prevention Research Center at Yale University's Schools of Public Health and Medicine, said, "Available data indicate we are concomitantly under-diagnosing and over-diagnosing ADHD, under- and over-treating it."

Costs of Missing the Diagnosis

ADHD causes significant lifelong impairment in those it affects. Left untreated, it affects financial status, educational achievements, relationships, and health.

"Overall, people with ADHD have less annual income," Biederman said. "This was true for males and females. Those with ADHD had income approximately $10,791 lower  per year among high school graduates, and about $4,334 lower for college graduates than their counterparts without ADHD."

Biederman said that the estimated yearly income loss for adults with ADHD in the United States is $77 billion. The numbers for drug abuse are $58 billion, alcohol abuse $85 billion, and depression $43 billion, he said. "You can see that ADHD is one of the costliest medical conditions we have," he said.

I have seen hundreds of patients who have suffered for decades with ADHD. Some may have suspected something wasn't right or that school and life were more difficult for them than their peers. When they learn more about ADHD, they realize their challenges are due to ADHD. They often wonder why their teachers, parents, and previous therapists or psychiatrists didn't pick up on the ADHD

For example, the other day, I saw a 26-year-old* who had been referred by his law school advisor for anxiety and depression.

This client never suspected that he had ADHD. He had performed well in high school and college and was accepted into a leading law school. Other therapists and psychiatrists had diagnosed him with depression, OCD, or generalized anxiety disorder and attempted to treat his symptoms with antidepressants and benzodiazepines. These medications would make him feel depressed, lethargic, and foggy.

As I explored his history, he told me that he was always well behaved as a child but would often daydream in class. He had difficulty socializing with his peers and felt like "the other kids were playing by rules that he was never taught." People often call him space cadet, and his parents tested him several times for his hearing because he seemed not to listen. He constantly lost his school supplies and had a messy desk and room. He did not do well in elementary school, and his parents often yelled at him about his poor grades. Instead, they hired tutors for him and set a rigorous and regimented study schedule that continued throughout junior high and high school. He started earning better grades and was proud of his performance. However, he still couldn't understand why it seemed to take him 2-3 times more time to do his work than it took his peers.

When he went to college, he struggled. Without the rigid structure his parents and school imposed, he became overwhelmed. His grades were mediocre, and he suffered from bouts of anxiety and depression.

My client was determined to attend law school and struggled with the application process. He did get accepted to a lower-ranked law school and decided to go. But, with the new demands of law school, his previous coping strategies were starting to fail. So he was getting further behind when he was finally referred to me for an assessment.

As It turned out, he did not have depression, anxiety, or OCD, but he had ADHD. His parents were shocked by the diagnosis. 

In addition, he related to me how he walked around in a fog most of the day and felt that he had cobwebs in his brain, the way that someone might when they first wake up in the morning or when they have the flu. However, this was how he had felt his entire life and assumed this was how other people also felt. He didn't realize that some people can focus, concentrate and stay on task without the need to rely on an excessive amount of effort and anxiety.

I started him on Adderall. Suddenly, a light bulb went off, the cobwebs cleared, and he saw the world the way most people do. In addition, his anxiety greatly diminished, and he finally had the hope to pursue his passions and life goals. 

Medications are not a total cure. With our work together, he learned strategies to improve his focus, organization and time management.

How to Diagnose Adult ADHD?

Adult ADHD is a clinical diagnosis made by an experienced mental health professional such as a psychologist or psychiatrist. Many clinicians were taught that if someone presents with depression and ADHD, first treat the depression, THEN treat the ADHD. Very often, the patient relates feeling depressed and frustrated; usually, this is because he has experienced one failure after another or jumped from one job to the next. In my experience, when you treat the ADHD, the person has the ability to pursue his goals both professionally and personally.

Unfortunately, many patients are misdiagnosed. They are treated with antidepressants, mood stabilizers, and other medications or treatments. 

In some instances, neuropsychiatric testing can be helpful, especially when there is a suspicion of a learning disorder, such as dyslexia. However, testing is not always indicated, nor is it always accurate. It is generally time-consuming, very costly, and may miss the diagnosis. For example, testing may show that a person's executive functioning, focus, and distractibility are normal, but testing is performed over a short period. A key feature of adult ADHD is that the symptoms are consistently inconsistent.


How to Help Our Clients with Adult ADHD-Five Key Tips

1. Screen All Clients

So, how can we help our clients with adult ADHD? First, it is vital to understand the impact that ADHD has on someone's life and that it is frequently misdiagnosed or under-diagnosed. It is essential to understand that ADHD does exist and that the stigma of ADHD and the anxiety about using stimulants keeps people from getting diagnosed and treated. 

It is essential to screen all clients for Adult ADHD by using a simple five-minute screening tool in the office or waiting room.

Here is a site that can be utilized as a screening tool:

http://counsellingresource.com/lib/quizzes/adhd-testing/adhd-asrs/

Many clients also feel that adult ADHD is not a "real diagnosis" and thus don't get evaluated or treated. However, explaining to the patients that SPECT and PET scans show differential blood flow in the prefrontal cortex in ADHD patients versus non-ADHD patients can help reinforce to the patient that this is a real issue.

2. Refer For An Assessment and Treatment

For a client with a high suspicion of adult ADHD, refer to a psychiatrist or psychologist specializing in ADD/ADHD for an assessment and treatment. Medications are a cornerstone of treatment and can be life-changing for many patients who have been suffering for decades with an inaccurate diagnosis and without effective treatments.

3. Cognitive Behavioral Therapy

Another cornerstone of treatment is developing strategies to address the specific individual and unique challenges.

"Cognitive behavior therapy has been successfully applied to this client group (Stevenson et al., 2002; Wilens et al., 1999). "Individuals with ADHD require structure in terms of personal organization, social boundaries, and practical help to cope with everyday problems" (Susan Young, 2007, pp 50)

CBT sessions can help them address their most critical challenges. Often, these challenges include difficulties with time management, prioritizing, strategizing, planning, mood regulation, social skills, organization, focus, and motivation.

It is essential to encourage your clients to purchase a weekly calendar and use it regularly instead of relying on post-it notes or a smartphone. Many ADHD patients do better when they see their schedule and tasks visually.

Another behavioral intervention for your clients is to teach them to develop a to-do list with a way to prioritize each item. Then, have them place the items at a specific time on the calendar. More structure can facilitate better outcomes.

If you do not specialize in CBT or the client has significant career challenges, hiring a coach to help the client overcome these specific challenges, develop strategies and increase accountability can help improve success in work and personal life. Coaching can be an essential piece of treatment, but it can be challenging to find an effective coach. Ideally, the coach should have extensive experience working with clients who have Adult ADD/ADHD.

4. Address the Shame

Growing up with diagnosed or undiagnosed ADHD can often lead to feelings of shame and defectiveness. There is often a significant shortfall in academics, career history, and relationships. Furthermore,  there is often a history of criticism by parents and teachers. 

Help the client see that they have many strengths and that ADHD is just one aspect of their identity. Validate that it may have been a difficult struggle and that their lives can improve significantly.

5. Minimize the Potential Fallout from ADHD

Even when a client understands some of the challenges that ADHD has created, it is often unclear how it has impacted other areas of their life. Help the client understand that many behaviors such as underperforming at work, engaging in high-risk sexual activity, or facing struggles in their personal relationships are pervasive in patients with ADHD. Reassure them that this can improve over time with treatment, medications, behavioral treatments, or a combination.

Conclusion

Adult ADHD is a severe disorder that affects all aspects of a client's life. However, many clients may not have received an accurate diagnosis or treatment for ADHD. 

However, overcoming the stigma that implies ADHD is not a "real diagnosis" and understanding its significant impact on a client's life and course of therapy can make a substantial difference to your client. In addition, screening for Adult ADHD in each of your clients, referring them for assessment and treatment, and utilizing cognitive behavioral therapy can significantly impact their lives.

To learn more about adult ADHD, visit my website which has many additional articles on adult ADHD.

*Disclaimer: Details of cases have been altered to protect the confidentiality of any and all individuals.
References:
Reinberg, Steven. Adult ADHD Costs Billions in Lost Income. HealthDay Reporter at HealingWell.Com. 2004. Retrieved from http://www.news.healingwell.com/indesx.php?p=news1&id=521145
Young, Susan et al.: ADHD in Adults; A Psychological Guide to Practice. John Wiley and Sons, Ltd. 2007
Wilens,T.E. Cognitive therapy in treating adults with ADHD: a systematic chart review of 26 cases. Journal of Cognitive Psychotherapy: an International Quarterly, 13, 215-226.

The Missing Link in Thriving with Adult ADHD: Overcoming Shame

by Scott Shapiro, MD - Specializing in Adult ADHD in New York City

How long have you been struggling in your life and feeling stuck?

• Do you often know exactly the “what” and “how” of what you need to do, but can’t execute?

• Have you had to work three or four times harder than everyone else just to keep up?

• Have you tried harder and harder, except can’t seem to achieve the level of professional competence you desire?

• Have you often wondered why you initially did well in school, maybe even excelled, but started having increased difficulties as the work became more challenging and your life became more complicated?

• Are you confused and wondering why you’re always procrastinating or not achieving your goals even though, deep down, you know how important your goals are?

• How hard has it been to live like this for so long?

Source: iStock PeopleImages

Many self-help articles and books on ADHD address the symptoms, challenges, and treatments, both medical and psychological. However, to cope most effectively with ADHD, it is essential to address the lifelong patterns and beliefs of shame that often accompany lifelong ADHD. Otherwise, your success living with ADHD may be limited—even with the help of an accurate diagnosis, medication and treatment. This is because the experience of chronic shame often becomes a firmly held belief of being less than, a failure or defective.

Beliefs create part of one’s identity and according to many theories of the mind and personality, beliefs are firmly held and resistant to change. Thus, paradoxically, an individual with a strong belief of shame may inadvertently perpetuate this belief by many mechanisms such as minimizing praise, ruminating about past and current failures, or spending time with critical people, either in professional or personal relationships.

Take Lucy* for example. She works as a research analyst at a consulting firm and has struggled with concentration, focus, and organization her entire life. Yet she has never been evaluated for ADHD.

At her last job review, she was placed on probation (the reason she called me for an appointment). Growing up, she was bullied and teased by her classmates for being a “space cadet.” Her parents often punished her for not doing her homework and getting low grades. They sometimes offered to help, but their frustration turned into irritability and Lucy felt like a failure. She thought she was a disappointment to them. Lucy’s teachers also often said she was so smart but “not living up to her potential.”
She knew the material and enjoyed learning; however, she felt demoralized by not being able to effectively do her work. She couldn’t figure out what was “broken” or wrong with her. She describes a life-long, painful journey of feeling defective, also known as shame.

She was finally diagnosed with ADHD in college and placed on medication, which significantly improved her core symptoms of poor motivation, low focus, disorganization, and impulsivity. However, she pursued a major in accounting which required significant attention to detail was very challenging to her. After graduation, she accepted a job as an internal financial auditor with a very critical boss. These events may seem like coincidences, but is quite a common pattern that I see in my patients with ADHD.

At work, whenever she is confronted with a challenge or task, she becomes anxious, flooded with memories of past failures and disappointments. Her anxiety and criticisms from her boss often causes her to avoid her work and procrastinate, thus reinforcing her anxiety and shame.

Shame is the chronic sense or feeling that there is something bad or broken about you, that you are defective or “less than” others. The origins of shame and defectiveness can vary: it might be due to any number of experiences or events. But frequently it stems from a child feeling different or defective, as a result of negatively impactful experiences and messages from family members or the outside world. Any experience that sends a message to the child that he or she is different and therefore “less than” can result in shame or a sense of defectiveness.

Such differences might be in socio-economic status, behavior compared to other children, ethnicity, medical problems, allergies, sexual orientation, learning differences…and even ADHD. Additionally, traumatic experiences—sexual or physical abuse and bullying—can create shame and defectiveness.

And shame is not only a feeling. It is also a belief that one is broken, damaged, or defective. Having this belief, this experience of shame, can create strong feelings of anxiety and fear. Beliefs are very powerful. Beliefs influence how we see ourselves, how we see our potential in the world.

Beliefs usually develop in childhood and are then perpetuated and reinforced throughout our lives. Researchers believe that our beliefs are influenced by and develop out of our natural, biological temperament and our environment.

One powerful way to address shame using CBT is to become more aware of the negative chatter in our own heads and to evaluate if there are some distortions. Many therapists call this negative chatter, the inner critic, that voice inside our head that creates doubts and worries, saying things like “you’ll never be able to complete this”, “this isn’t good enough”, “you aren’t smart enough”. However, the inner critic may be stronger in people with ADHD due to childhood struggles.

CBT is a powerful, evidenced based treatment that focused on the interaction between thoughts, behaviors and feelings. One key element of CBT is that the stories and thoughts we tell ourselves affects how we feel and what we believe.

Does this voice sound familiar? This toxic voice tends to make you more critical of yourself and others. It can take the “wind our of your sails”, sap your energy, love and creativity, and exacerbate your already challenged symptoms of focus, concentration and motivation. It can be particularly strong if you grew up around critical adults and peers.

Here are four steps to fight the inner critic.

First, become more aware of the voice and when it pops up. Mindfulness can help and so can realizing your own red flags such as feeling bored anxious, or paralyzed. When you notice it, label it. “Oh, there is the inner critic.”

Second, write out what the inner critic is saying. Some examples include:

“I will never get this project done.”
“I am going to get fired.”
“There is something wrong with me.”
“I can’t focus.”
“I can’t do my work.”
“I will never learn this.”

Third, notice what type of inner critic is it. Is it blaming, negative, critical etc.

Fourth, use counter statements that are prepared ahead of time. Be open to them even though may sound like “positive thinking” or wishful thinking like on Saturday Live memorialized in the 1990s. Research has demonstrated the power and impact. Some examples include:

“Done is better than perfect”
“I am a work in progress”
“I can take my time”
“I don’t have to please everyone”

Give this technique a try. I often recommend that people record the counter statements on a card or on their smartphones. I have worked with thousands of patients and have found this to be an effective strategy for many of my patients in overcoming shame from ADHD.

To receive quarterly newsletters at no charge, go to this link:

Dr. Shapiro’s Adult ADHD Newsletter 

*Disclaimer: Details of cases have been altered to protect the confidentiality of any and all individuals.

Adult ADHD: 7 Tips to Energize Your Life

Adult ADHD: 7 Tips to Energize YourLife

Source: istock photo: michaelpuche

Adult ADHD: 7 Tips to Energize YourLife

Tina*, a 27 year-old married graduate student, presented to my office years ago when I first started my practice. She described chronic anxiety, low mood, and trouble sleeping for the past two years. She had been struggling with “keeping up with it all”. This included schoolwork, relationships, a part-time job, and a one year-old baby. 

In the past, she had been diagnosed with anxiety disorders and depression. Her doctor tried her on two antidepressants that both caused intolerable side effects. When I met with her, the top complaints were feeling overwhelmed and discouraged.

After an extensive evaluation, I diagnosed her with ADHD, inattentive type. She did not have depression or an anxiety disorder. She responded extremely well to medication and his mood and anxiety improved as she became more organized and competent in her life.

However, despite ADHD treatment with medications and therapy, she continued to exert significant energy “just to keep up”. This is often true with adults with ADHD. In addition to focus, procrastination, and distractibility, ADHD affects a set of cognitive skills known as executive functions. Executive functions include long-term planning, follow through, prioritizing, strategizing, time-management and other complex thinking skills. Deficits in executive function often persist despite ADHD medication treatment and require both extra effort and specific coping strategies.

Therefore, people with ADHD often experience difficulty maintaining their energy. Here are some tips to energize your life as you cope with ADHD. I hope they help you on your journey to success. 

1.  OBSERVE RUMINATION

Rumination is thinking about the same thing over and over. It can sap your energy and take the “wind out of your sails”. People with Adult ADHD may be more prone to rumination due to difficulty shifting gears.

Attempting to stop the thoughts can often make them persist. Instead, label them as “ruminating thoughts” and turn your focus to another activity.  One technique that you may find helping is saying,  “Oh…there is obsessing”, or “Oh…there is worry”. Just observe what happens when you name the thought. Research has shown that this can lower the intensity and duration.

2.  INCREASESTRUCTURE

People with ADHD often struggle with a cluster of cognitive skills called executive function such as time management, initiating tasks, organization, follow through, and prioritizing. Challenges in executive function can lead to anxiety and feeling exhausted.

Having a schedule or “game plan”, can help one feel calmer.  Using a calendar, either paper or digital, can help structure tasks and time. This can help with productivity and organization.

3.  SELF-TALK

Many people with Adult ADHD often feel they never are going to catch up or achieve their goals. This may be due to painful experiences in the past. You may recognize some of the self-talk:

●      “I am always screwing things up”.

●      “I will never be good enough”.

●      “This will never work for me”.

This type of self-talk is often called the inner critic and can sap energy similar to rumination. Often, I encourage my patients to do the following:

●      Notice the inner critic.

●      As above, label it. “Oh….There is the inner critic.”

●      Remind yourself: “I am a work in progress”.

This may just sound like positive talk or unrealistic, but thousands of studies for many decades have shown that how we talk to ourselves affects how we feel and behave.

4.  IMPROVE SLEEP

There has been more attention over the past decade on sleep and the impact of sleep deprivation.  Restorative and adequate sleep is important not only for energy but also for cognitive functioning. Sometimes, ADHD symptoms may worsen during periods of interrupted sleep, insomnia, or sleep deprivation. 

Some tips to improve intermittent sleeping difficulties include:

●      Avoiding electronic devices for three to four hours prior to bedtime.

●      Establishing a consistent, evening routine.

●      Creating a calm, uncluttered sleeping environment.

●      Using earplugs or a white noise machine if needed.

●      Exercising during the day and not within three hours of bedtime.

If you suffer from significant low energy during the day or chronic insomnia, it is important to seek treatment from your doctor about potential underlying medical causes of fatigue.

5.  FUN

Often, people with ADHD feel so overwhelmed or without enough time that fun or pleasurable activities are ignored. People may say, “I don’t have time to relax or have fun” or “I don’t deserve to do that”.  However, fun can energize you and help you have a better outlook and be more productive. Fun can involve watching a comedy, playing with your dog, visiting friends, or pursuing an artistic passion.

6.  SET GOALS

Just like a map, having specific goals can help you stay on track. As you make progress in your goals, it can provide momentum and guidance on your journey. I would recommend that you set several create both short-term (e.g. one month) and long-term (e.g. one year) goals.

Effective goals usually have specific outcomes (e.g. increased sales by $10,000 or eating meals with the family three times a week), a game plan or strategy, and most importantly, a means to measure the outcome (e.g. a chart or checklist).

7.  CARDIOVASCULAR EXERCISE

Cardiovascular exercise such as biking, running, dancing, swimming and other activities are good for our overall health. In addition, cardiovascular exercise can improve our sense of well-being and energy.

There are many hypotheses why cardiovascular exercise has this benefit including releasing endorphins and increasing a “motivational transmitter” called dopamine.

IN SUMMARY

Adult ADHD can be very challenging as you pursue success in your personal and professional life. However, I hope these seven ideas help to provide you the stamina and energy to achieve your potential.

If you would like to learn more about Adult ADHD and coping strategies, please visit my website at www.scottshapiromd.com.

*Disclaimer: Details of cases have been altered to protect the confidentiality of any and all individuals.

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