Treating AD/HD versus Managing AD/HD

About 5% of the adult population experience Attention-Deficit/Hyperactivity Disorder – AD/HD. AD/HD is a neuro-atypical condition. “Neuro-atypicality” means that a person who lives the experience of AD/HD has a different brain structure and functioning to the majority. People vary as to the degree of neuro-atypicality they experience. Some neuro-atypical people really struggle trying to live in the majority neurotypical world. Others seem to experience some degree of difficulty but have found ways to cope well enough. Almost always, however, getting through the day causes more stress, more anxiety and more fatigue than neurotypical people experience. Unrecognised; undiagnosed; and, untreated AD/HD certainly causes difficulties not only for those who experience it but for those in their life-space. It has been noted it causes or contributes towards increased risk-taking and what can follow – injury or even death. Research has shown it can lead to a reduced life-span.

When the presence of AD/HD is recognised and acknowledged there is naturally a desire to find a way to cope with the activities of daily living better. Understandably, there is the hope that AD/HD might be “cured”. But, unfortunately the term “cured” assumes disease or injury. Thinking in terms of “illness” and “cure” is misleading and frustrating. Instead, adopting the thinking that whilst AD/HD cannot be cured in favour of thinking that it can be managed will be optimal and lead to better outcomes.

How is AD/HD managed? There are several approaches that have backing from research and experience. I refer to my approach as being “E2”, i.e. empirical plus experience – empirically based practice with practice-based experience.

Ideally, E2, over the decades of my professional practice has demonstrated that managing AD/HD (ADHD) typically involves a combination of psycho-pharmacological medication and behavioural, and sometimes social, therapy. The two go hand in hand. The goal of management is to reduce behaviours that cause inattention, hyperactivity, and impulsivity and to increase functional behaviours in daily life. Some behaviours, that previously did not exist, may need to be established, others may need to be extinguished.

There are a minority who hold the view that AD/HD can be managed without medication. I am in the majority who believe that a neurological dysfunction logically requires a pharmacological intervention as an essential component in managing AD/HD. I have not yet encountered a case of successful management of AD/HD wherein a significant and sustained change of dysfunctional to functional behaviours was achieved without medication.

Medications do not simply remove the AD/HD behaviours. They reduce them so that alternative functional behaviours can be established and maintained. The prescribing professional will factor in the most suitable form of medication; dosage; and, ingestion regime (short acting or slow release, long acting). The most commonly prescribed medications for ADHD are stimulants. These include methylphenidate (Ritalin, Concerta, etc) and amphetamines (Adderall, etc). They help by increasing the levels of chemicals in the brain, e.g. dopamine and norepinephrine, that improve attention and reduce impulsivity. Medications generally produce an effect noticeable to the individual taking them but often also noticeable to others in their life-space. Usually, an effect can be evident within 15-20 minutes of ingestion. Medication can be taken daily as prescribed by the doctor. The effect is no longer evident in the longer term beyond the day the medication is taken. For people for whom stimulant medication may be contra-indicated, or in the doctor’s opinion, other non-stimulant medications, such as atomoxetine (Strattera) may also be prescribed.

Behavioural therapy, ranging from Applied Behaviour Analysis to CBT and its variants, is an effective adjunct to managing ADHD.  But, it needs to be employed in combination with medication to yield significant and sustained change. In the case of children and teenagers, behavioural therapies may include parent training and Applied Behaviour Analysis, in addition to social skills training to manage dysfunctional behaviours and improve social and academic functioning. It is a rare adult who needs social training. Some, however, will benefit from it.

With respect to children and adolescents especially, occupational therapists can help individuals manage AD/HD by teaching organisation and time management skills, as well as functional skills related to activities of daily living. Also, counselling or psychotherapy (e.g. CBT, ACT) can help those experiencing AD/HD learn coping strategies; better problem-solving skills; improve self-esteem; and foster relationships. In some cases, parenting training may be required to help manage the behaviour of children experiencing AD/HD and improve family interactions.

In conclusion, it is important to note that people can respond differently to different treatment approaches. Hence, working closely with a mental health professional to find the most effective treatment plan is advisable. It is also essential to note that AD/HD is a permanent (those seeing it within the medical model would say “chronic”) condition, so ongoing management and support is essential.