Continuing Medical Education

Even though the new DSM-5¹ has improved screening for adult ADHD, the health and social services system is not yet adapted to help adults who consult for ADHD and does not offer timely access to specific treatments, especially non-pharmacological ones, such as cognitive-behavioural therapy (CBT).

You tell Peter that several strategies have proven effective as an adjunct to drug therapy for improving the functioning of adults with ADHD. These include time management, space management, task management and emotional management. Some psychotherapy models have been published in the form of guidebooks (in either individual^2-5 or group⁶ settings). Popular self-help books also deal with this topic.^7,8 Dr. Ramsay and Dr. Rostain propose strategies allowing clinicians to integrate these approaches with drug therapy.⁹ During the assessment process, you had already given Peter a pamphlet listing resources available to help him (readings and websites, contact information for an ADHD support group, the CLSC, psychologists, occupational therapists, and ADHD coaches in private practice). Thinking that he could handle this on his own, Peter threw it away.

Changing habits or attitudes is never an easy thing to do. This is where “motivation to change” comes into play. According to the stages outlined by Prochaska and DiClemente and presented in Table 1,¹⁰ Peter is in the contemplation stage: he recognizes or is aware that he needs help but is ambivalent, analyzing his possible options for the time being.

Targeting specific objectives helps choose strategies. This article proposes a selection of tools that can help adults with ADHD in this process. Some situations require specialist follow-up. Specific psychological treatment can help people to identify and question their negative thought bias and to work on motivational aspects. Occupational therapists, educators or trained coaches can also work with them to set up and apply effective daily routines.

The support documents identified by pictograms can be found in the Tips section at www.cliniquefocus.com/ and www.attentiondeficit-info.com/. Readers using the online version of Le Médecin du Québec can access the documents mentioned in this article by clicking on the different icons in the Toolbox 1 section.

Practical tips for active psychoeducation

Psychoeducation is a major but underestimated step in the therapeutic process. When you simply give patients a pamphlet, you might have the impression of having done your job. However, it is important to follow up with them to see if they have read and used the information in it.

Practical Tips for Academic Achievement

Peter is starting evening classes. ADHD can lead to difficulties in school (see the article “ADHD: Truths and Misconceptions”). You inform him about possible accommodations, such as:

The decision to implement adaptive measures depends more on functional impairments than on the presence or absence of a disorder and must be individually tailored to the effects on school functioning. These measures should therefore not be automatically applied for everyone with a dysphasia, a learning disability (e.g., dyslexia, dysorthographia) or ADHD. If it is possible and the tools readily accessible, a trial period can help support their use. These measures are determined by the school administration for younger students and by the adaptive services teams for college and university students. A neuropsychological assessment can be an asset but is not essential for choosing the necessary type of accommodation and should therefore not be required by the teaching staff. In Québec, support programs and grants for students with disabilities may help cover the costs of certain measures and can be invaluable to these students. Physicians play a key role in helping students receive these measures, given that physicians are some of the professionals authorized to certify that ADHD is hindering student learning on the financial assistance application form (Application for Financial Assistance – Loans and Bursaries Program).

Practical time management tips

Peter is often late or at the last minute. Time eludes him; his to-do list is getting longer and longer, and he cannot find the time . . . to manage his time ! Although many people view time management and daily routines as utterly useless and boring, both are major components in ADHD treatment.

Young adults are particularly prone to poor time management. They feel overwhelmed by their growing number of obligations, combined with a decrease in external support (e.g., less parental supervision). At a certain point in life, adults seek medical advice to reduce the effects of ADHD because they are no longer able to function despite the strategies they are using. The solution: finding a new way to work! Here are a few tips:

Practical space management tips

Peter is late. He had misplaced his keys . . . again! Besides managing their time better, adults can benefit from organizing their space to reduce the effects of ADHD. Many get discouraged because they don’t know where to start or are unable to stick to their good intentions. Here are a few winning strategies:

Practical tips for healthy financial management

Peter would like to improve his financial situation. Impulse buying and forgetting to pay bills are never winning solutions. Poor financial management can negatively impact your personal life and relationships, especially with your romantic partner.

Plan out your expenses

Pay bills on time

Delegate and take advice

Practical emotional management tips

Peter tends to quickly lose control and fly into rages. His impulsivity stops him from taking a step back to analyze the situation. He reacts rather than acts. The hyperactivity associated with ADHD gives the feeling of riding an emotional roller-coaster and has significant impacts on relationships. People regret their impulsive overreactions and fear them so much that they avoid all risky situations and isolate themselves.

Tips for acting instead of reacting

When you are about to erupt . . . take time out to relax and to change your ideas (Toolbox 3).

Once patients have better control over their emotional outbursts, it is time to initiate an introspective process to deal with their automatic negative thoughts. Becoming aware of cognitive distortions allows people to undertake a cognitive restructuring exercise. This process is designed to lead them to intercept their automatic thoughts and to raise reasonable doubts about them (Table 2).

The chart developed by Ramsay and Rostain,⁹ which identifies common cognitive distortions in adults with ADHD, helps initiate a cognitive approach. A summary of the four-step cognitive restructuring exercise, along with examples, can be found in the document “Cognitive Restructuring 101” (see Icon VI in Toolbox 1). This type of technique is effective for managing not only anxiety but depression as well.¹¹

Using Ramsay and Rostain’s cognitive distortion chart,⁹ Peter realized that he has been prone to magical thinking since he received his ADHD diagnosis and his doctor prescribed medication for it. Table 2 shows the cognitive restructuring exercise he performed following this realization.

Now it’s time to walk the walk! It’s not enough to talk about it. You have to do something about it! The exposure technique helps to gradually tame your negative emotions (e.g., performance anxiety) that generally provoke avoidance behaviour (e.g., ten-minute strategy, see the section “Practical Time Management Tips”).

Practical tips for finding balance in your life

Peter has been burning the candle at both ends. He is tired because of his unbalanced lifestyle. Knowing that ADHD can prevent people from adopting and maintaining a healthy lifestyle, you explain that poor nutrition, insufficient sleep and a sedentary lifestyle exacerbate the symptoms. Here are a few tips to break this vicious circle:

ADHD and sleep (bedtime habits)¹²

ADHD and nutrition

ADHD and physical activity

Breaking isolation and finding support:
ADHD support groups

Choosing someone close to you to confide in can improve how each of you understands ADHD. Some people become excellent daily life counsellors and coaches. Support groups help you get informed, receive support and break your isolation. In Québec, find your nearest support group (e.g., PANDA at www.associationpanda.qc.ca/) and, for the rest of Canada, visit CADDAC (www.caddac.ca/ cms/page.php?2).

Nathan’s family and you have come a long way. Together, you have overcome the barriers associated with ADHD and you can now see positive results from this process. Your patients have gained benefits, and you have gained a sense of having been able to make a difference. And look, you’re ready to do it again! Didn’t we tell you: screening and treating ADHD can be addictive! //

French Version: Received: January 27, 2013 Accepted:April 17, 2013
Translated in English: September, 2014

Dr. Nicolas Julien and Jean-François Giguère have no conflicts of interest to declare. Dr. Annick Vincent is a speaker and an advisory committee member for Biovail, Lundbeck, Bristol Myers Squibb, Lilly, Purdue, Janssen and Shire. She received grants from Purdue, Shire and Janssen from 2011 to 2013.

References

• 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-V). 5^th ed. Washington: American Psychiatric Association Publishing, 2013. Website: www.psychiatry.org/dsm5 (Accessed: January 22, 2013).
• 2. Lafleur M, Pelletier MF, Vincent MF et al. La maîtrise du TDAH chez l’adulte. Un programme de thérapie cognitive comportementale. Guide du thérapeute. Québec : Direction de l’enseignement de l’ISMQ, 2010. Website : www.institut smq.qc.ca/fileadmin/publications/maitrise-tdah-adulte-therapeute.pdf (Accessed: February 14, 2013).
• 3. Lafleur M, Pelletier MF, Vincent MF et al. La maîtrise du TDAH chez l’adulte. Un programme de thérapie cognitive comportementale. Guide du client. Québec: Direction de l’enseignement de l’ISMQ, 2010.
• 4. Safren SA, Sprich S, Perlman CA et al. Mastering your Adult ADHD, a cognitive behavioral treatment program. Therapist Guide. New York: Oxford, 2005.
• 5. Safren SA, Sprich S, Perlman CA et al. Mastering your adult ADHD. A cognitive behavioral treatment program. Client Workbook. New York: Oxford, 2005.
• 6. Solanto M. Cognitive-behavioral therapy for adult ADHD: targeting executive dysfunction. New York: Guilford Press, 2011.
• 7. Vincent A. My brain Still Needs Glasses. Montreal: Québec Livres, 2013.
• 8. Sarkis SM. 10 Simple Solutions to Adult ADD. Oakland: New Harbinger Publications, Inc. 2011.
• 9. Ramsay JR, Rostain AL. Cognitive-behavioral therapy for adult ADHD. An integrative psychosocial and medical approach. 1^st ed. New York: Routledge, 2007.
• 10. Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research & Practice 1982; 19(3): 276-88.
• 11. Burns, D. D. Feeling Good: The New Mood Therapy (preface by Aaron T. Beck). New York: Harper Collins Books Revised and updated, 1999.
• 12. Morin C. Relief from Insomnia: Getting the Sleep of Your Dreams. New York : Doubleday, 1996.
• 13. Ratey JJ. Spark: The Revolutionary New Science of Exercise and the Brain. New York: Little Brown and Company, 2008.