Therapy Plan for ADHD

A detailed outline and overview of the therapy process for individuals with the issues

associated with Adult Attention Deficit Disorder

About ADHD: Overview

Everybody can have difficulty sitting still, paying attention or controlling impulsive behavior once in a while. For some people, however, the problems are so pervasive and persistent that they interfere with every aspect of their life: home, academic, social and work.

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting 11 percent of school-age children. Symptoms continue into adulthood in more than three-quarters of cases. ADHD is characterized by developmentally inappropriate levels of inattention, impulsivity and hyperactivity.

Individuals with ADHD can be very successful in life. However, without identification and proper treatment, ADHD may have serious consequences, including school failure, family stress and disruption, depression, problems with relationships, substance abuse, delinquency, accidental injuries and job failure. Early identification and treatment are extremely important.

Medical science first documented children exhibiting inattentiveness, impulsivity and hyperactivity in 1902. Since that time, the disorder has been given numerous names, including minimal brain dysfunction, hyperkinetic reaction of childhood, and attention-deficit disorder with or without hyperactivity. With the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) classification system, the disorder has been renamed attention-deficit/hyperactivity disorder or ADHD. The current name reflects the importance of the inattention aspect of the disorder as well as the other characteristics of the disorder such as hyperactivity and impulsivity.

Retrieved from: https://chadd.org/about-adhd/overview/

Symptoms

Typically, ADHD symptoms arise in early childhood. According to the DSM-5, several symptoms are required to be present before the age of 12. Many parents report excessive motor activity during the toddler years, but ADHD symptoms can be hard to distinguish from the impulsivity, inattentiveness and active behavior that is typical for kids under the age of four. In making the diagnosis, children should have six or more symptoms of the disorder present; adolescents 17 and older and adults should have at least five of the symptoms present. The DSM-5 lists three presentations of ADHD—Predominantly Inattentive, Hyperactive-Impulsive and Combined. The symptoms for each are adapted and summarized below.

ADHD predominantly inattentive presentation

• Fails to give close attention to details or makes careless mistakes
• Has difficulty sustaining attention
• Does not appear to listen
• Struggles to follow through with instructions
• Has difficulty with organization
• Avoids or dislikes tasks requiring sustained mental effort
• Loses things
• Is easily distracted
• Is forgetful in daily activities

ADHD predominantly hyperactive-impulsive presentation

• Fidgets with hands or feet or squirms in chair
• Has difficulty remaining seated
• Runs about or climbs excessively in children; extreme restlessness in adults
• Difficulty engaging in activities quietly
• Acts as if driven by a motor; adults will often feel inside as if they are driven by a motor
• Talks excessively
• Blurts out answers before questions have been completed
• Difficulty waiting or taking turns
• Interrupts or intrudes upon others

ADHD combined presentation

• The individual meets the criteria for both inattention and hyperactive-impulsive ADHD presentations.

These symptoms can change over time, so children may fit different presentations as they get older.

Confusing labels for ADHD

In 1994, the name of the disorder was changed in a way that is confusing for many people. Since that time all forms of attention deficit disorder are officially called “Attention-Deficit/Hyperactivity Disorder,” regardless of whether the individual has symptoms of hyperactivity or not. Even though these are the official labels, a lot of professionals and lay people still use both terms: ADD and ADHD. Some use those terms to designate the old subtypes; others use ADD just as a shorter way to refer to any presentation.

Severity of symptoms

As ADHD symptoms affect each person to varying degrees, the DSM-5 now requires professionals diagnosing ADHD to include the severity of the disorder. How severe the disorder is can change with the presentation during a person’s lifetime. Clinicians can designate the severity of ADHD as “mild,” “moderate” or “severe” under the criteria in the DSM-5.

Mild: Few symptoms beyond the required number for diagnosis are present, and symptoms result in minor impairment in social, school or work settings.
Moderate: Symptoms or functional impairment between “mild” and “severe” are present.
Severe: Many symptoms are present beyond the number needed to make a diagnosis; several symptoms are particularly severe; or symptoms result in marked impairment in social, school or work settings.

As individuals age, their symptoms may lessen, change or take different forms. Adults who retain some of the symptoms of childhood ADHD, but not all, can be diagnosed as having ADHD in partial remission.

ADHD throughout the lifespan

Children with ADHD often experience delays in independent functioning and may behave younger than their peers. Many children affected by ADHD can also have mild delays in language, motor skills or social development that are not part of ADHD but often co-occur. They tend to have low frustration tolerance, difficulty controlling their emotions and often experience mood swings.

Children with ADHD are at risk for potentially serious problems in adolescence and adulthood: academic failure or delays, driving problems, difficulties with peers and social situations, risky sexual behavior, and substance abuse. There may be more severe negative behaviors with co-existing conditions such as oppositional defiant disorder or conduct disorder. Adolescent girls with ADHD are also more prone to eating disorders than boys. As noted above, ADHD persists from childhood to adolescence in the vast majority of cases (50–80 percent), although the hyperactivity may lessen over time.

Teens with ADHD present a special challenge. During these years, academic and life demands increase. At the same time, these kids face typical adolescent issues such as emerging sexuality, establishing independence, dealing with peer pressure and the challenges of driving.

More than 75 percent of children with ADHD continue to experience significant symptoms in adulthood. In early adulthood, ADHD may be associated with depression, mood or conduct disorders and substance abuse. Adults with ADHD often cope with difficulties at work and in their personal and family lives related to ADHD symptoms. Many have inconsistent performance at work or in their careers; have difficulties with day-to-day responsibilities; experience relationship problems; and may have chronic feelings of frustration, guilt or blame.

Individuals with ADHD may also have difficulties with maintaining attention, executive function and working memory. Recently, deficits in executive function have emerged as key factors affecting academic and career success. Executive function is the brain’s ability to prioritize and manage thoughts and actions. This ability permits individuals to consider the long-term consequences of their actions and guide their behavior across time more effectively. Individuals who have issues with executive functioning may have difficulties completing tasks or may forget important things.

Co-occurring Disorders

More than two-thirds of children with ADHD have at least one other co-existing condition. Any disorder can co-exist with ADHD, but certain disorders seem to occur more often. These disorders include oppositional defiant and conduct disorders, anxiety, depression, tic disorders or Tourette syndrome, substance abuse, sleep disorders and learning disabilities. When co-existing conditions are present, academic and behavioral problems, as well as emotional issues, may be more complex.

These co-occurring disorders can continue throughout a person’s life. A thorough diagnosis and treatment plan that takes into account all of the symptoms present is essential.

Causes

Despite multiple studies, researchers have yet to determine the exact causes of ADHD. However, scientists have discovered a strong genetic link since ADHD can run in families. More than 20 genetic studies have shown evidence that ADHD is strongly inherited. Yet ADHD is a complex disorder, which is the result of multiple interacting genes.

Other factors in the environment may increase the likelihood of having ADHD:

• exposure to lead or pesticides in early childhood
• premature birth or low birth weight
• brain injury

Scientists continue to study the exact relationship of ADHD to environmental factors, but point out that there is no single cause that explains all cases of ADHD and that many factors may play a part.

Previously, scientists believed that maternal stress and smoking during pregnancy could increase the risk for ADHD, but emerging evidence is starting to question this belief. However, further research is needed to determine if there is a link or not.

The following factors are NOT known causes, but can make ADHD symptoms worse for some children:

• watching too much television
• eating sugar
• family stress (poverty, family conflict)
• traumatic experiences

ADHD symptoms, themselves, may contribute to family conflict. Even though family stress does not cause ADHD, it can change the way the ADHD presents itself and result in additional problems such as antisocial behavior.

Problems in parenting or parenting styles may make ADHD better or worse, but these do not cause the disorder. ADHD is clearly a brain-based disorder. Currently research is underway to better define the areas and pathways that are involved.

Retrieved from: https://chadd.org/about-adhd/overview/

Presenting Problems: symptoms and behavioral definitions

• Childhood history of Attention Deficit Disorder (ADD) that was either diagnosed or later concluded due to the symptoms of behavioral problems at school, impulsivity, temper outbursts, and lack of concentration.
• Unable to concentrate or pay attention to things of low interest, even when those things are important to his/her life.
• Easily distracted and drawn from task at hand.
• Restless and fidgety; unable to be sedentary for more than a short time.
• Impulsive; has an easily observable pattern of acting first and thinking later.
• Rapid mood swings and mood lability within short spans of time.
• Disorganized in most areas of his/her life.
• Starts many projects but rarely finishes any.
• Has a “low boiling point” and a “short fuse.”
• Exhibits low stress tolerance; is easily frustrated, hassled, or upset.
• Chronic low self-esteem.
• Tendency toward addictive behaviors.

Long Term Goals of Therapy

1. Reduce impulsive actions while increasing concentration and focus on low-interest activities.
2. Minimize ADD behavioral interference in daily life.
3. Accept ADD as a chronic issue and need for continuing medication treatment.
4. Sustain attention and concentration for consistently longer periods of time.
5. Achieve a satisfactory level of balance, structure, and intimacy in personal life.

The treatment plan, therapy outline, goals, objectives, and interventions are subject to change as your therapist develops new skills, attains new certifications, and integrates new material into this website. You may or may not be given notice of any changes in advance of updates to this page.

Assessment

• You will be asked to describe your past and present experiences with ADD including its effects on functioning.
  • We will establish rapport and trust toward building a therapeutic alliance.
  • We will complete a thorough psychosocial assessment including past and present symptoms of ADD and their effects on educational,
    occupational, and social functioning.
• You may be asked if you would like to cooperate with and complete psychological testing.
  • We will arrange for psychological testing to further assess ADD, other possible psychopathology (e.g., anxiety, depression), and relevant rule outs (e.g., ADHD, conduct/antisocial features)
  • I can provide you with feedback of the testing results.
• You may be asked if you would like to cooperate with and complete a Psychiatric evaluation.
  • We will arrange for a psychiatric evaluation to rule out medical and substance related etiologies and assess the need for psychotropic
    medication.
• You will be asked to comply with all recommendations based on the psychiatric and/or psychological evaluations.
  • We will process the results of the psychiatric evaluation and/or psychological testing and I can answer any questions that may arise.
  • We could conduct a conjoint session with significant others to present the results of the psychological and psychiatric evaluations; answer any questions they may have and solicit their support in dealing with ADHD.
• You will be asked to disclose any history of substance use that may contribute to and complicate the treatment of ADD.
  • You will be asked to complete a substance use evaluation and possibly be referred for inpatient or residential treatment if the evaluation recommends it.
• You will be asked to provide behavioral, emotional, and attitudinal information toward determining specifiers relevant to a DSM diagnosis, for insurance billing and licensing requirements, the efficacy of a therapy plan, and the nature of the therapy relationship.
  • We will discuss the stages of change theory, and assess your level of insight (syntonic versus dystonic) toward the “presenting problems”
    • Do you demonstrate good insight into the problematic nature of the “described behavior,” agreeing with others’ concern, and motivated
      to work on change
    • Do you demonstrate ambivalence regarding the “problem described” and reluctant to address the issue as a concern
    • Or, do you demonstrate resistance regarding acknowledgment of the “problem described,” not concerned, and have no motivation to change.
  • We will assess for evidence of any research-based correlated disorders (e.g., oppositional defiant behavior with ADHD, depression secondary to an anxiety disorder) including vulnerability to suicide, if appropriate (e.g., increased suicide risk when comorbid depression is evident).
  • We will assess for any issues of age, gender, or culture that could help explain the currently defined “problem behavior” and factors that could offer a better understanding of the behavior.
  • We will assess for the severity of the level of impairment to functioning to determine appropriate level of care
    • (e.g., the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors)
  • We will continuously assess this severity of impairment as well as the efficacy of treatment
    • (e.g., the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment).

Psychoeducation

Session Agenda

Psychopharmacology & Medication Adherence

• Take psychotropic medication as prescribed, on a regular, consistent basis.
  • Monitor and evaluate the client’s psychotropic medication prescription compliance, side effects, and the effectiveness of the medications on his/her level of functioning.
  • Confer with the client’s psychiatrist on a regular basis regarding the effectiveness and side effects of the medication regimen.
• Identify specific benefits of taking prescribed psychotropic medications on a long-term basis.
  • Ask the client to make a “pros and cons” spreadsheet regarding staying on psychotropic medications; process the results.
  • Encourage and support the client in remaining on psychotropic medication and warmly but firmly confront thoughts of discontinuing when they surface
  • “Why I Dislike Taking My Medication” The Adult Psychotherapy Homework Planner by Jongsma.

Identifying Problems & Consequences

• Identify the current specific ADD behaviors that cause the most difficulty.
  • Assist the client in identifying the current specific behaviors that cause him/her the most difficulty functioning as part of identifying treatment targets (i.e., a functional analysis).
  • Review the results of psychological testing and/or psychiatric evaluation again with the client assisting in identifying or in affirming his/her choice of the most problematic behavior(s) to address.
  • Ask the client to have extended family members and close collaterals complete a ranking of the behaviors they see as interfering the most with his/her daily functioning (e.g., mood swings, temper outbursts, easily stressed, short attention span, never completes projects).
• List the negative consequences of the ADD problematic behavior.
  • Assign the client to make a list of negative consequences that he/she has experienced or that could result from a continuation of the problematic behavior; process the list (or assign “Impulsive Behavior Journal” in the Adult Psychotherapy Homework Planner by Jongsma).

Conjoint Therapy Sessions

Invite a significant other to join in the therapy to provide support throughout therapy.

• At some point, you and I may discuss the possibility of inviting your significant other to participate in one or more therapy sessions; with the goal of educating them throughout therapy to help support the change and reduce friction in the relationship introduced by the ADHD symptoms and traits.
• We will work together with your significant other using the HOPE technique (i.e., Help, Obligations, Plans, and Encouragement) to help support positive changes.
• You may also want to purchase the book, “Driven to Distraction” by Hallowell and Ratey.

Organization and Planning

While completing this section, you will learn and implement organization and planning skills.

• Develop and implement structured organization and planning skills including the routine use of a calendar and daily task list.
• Develop a procedure for classifying and managing mail and other papers.
• Learn and implement problem-solving skills as an approach to planning; for each plan, break it down into manageable time-limited steps to reduce the influence of distractibility.
  • Identify your problem
  • Brainstorm all your possible options
  • Evaluate the pros and cons of each option
  • Select your best option
  • Implement a course of action
  • Evaluate the results of that decision
• You will be asked to complete a worksheet in between sessions
  • Problem-Solving: An Alternative to Impulsive Action in the Wiley ‘Adult Psychotherapy Homework Planner’ by Jongsma
• You will be asked to apply these new problem-solving skills to an everyday problem (i.e., impulse control, anger outbursts, mood swings, staying on task, attentiveness); I will review your progress with you and provide corrective feedback toward improving the skill.

 

Lesson: ADHD and Managing Your Money

Lesson: ADHD and Time Management

Lesson: ADHD and Organizing (Home and Work)

Activity 04-01: Problem Solving – An Alternative to Impulsive Action

Skills to Reduce Distractibility

While completing this section you will learn and implement skills to reduce the disruptive influence of distractibility.

• We will assess your typical attention span by having you do a few “boring” tasks (e.g., sorting bills, reading something uninteresting) to the point that they report distraction; we will use this as an approximate measure of your typical attention time span.
• Learn and practice stimulus control techniques that use external structure (e.g., lists, reminders, files, daily rituals) to improve on-task behavior; you will remove distracting stimuli in the environment; I encourage you to reward yourself for successful focus and follow-through.
• Learn how to break down tasks into meaningful smaller units that can be completed without being distracted based on your demonstrated attention time span.
• Learn how to use timers or other cues to remind yourself to stop tasks before you get distracted in an effort to reduce the time you may get distracted and off-task.
• We will adhere to the book: ‘Mastering Your Adult ADHD: Therapist Guide’ by Safren, et al.

Self Talk

Identify, challenge, and change self-talk that contributes to maladaptive feelings and actions.

• We will use cognitive behavioral therapy techniques to help you identify maladaptive self-talk (e.g., “I must do this perfectly,” “I can do this later,” “I can’t organize all these things”)
• We will use CBT skills to challenge your cognitive biases, and generate alternative self-talk.
• You will be assigned homework and asked to implement cognitive restructuring skills while doing tasks in which maladaptive thinking has occurred previously
• We will review your progress and I will provide you helpful corrective feedback toward improving the skills.

Skills to Reduce Procrastination

After completing this section, you will be able to acknowledge procrastination and the need to reduce it.

• We will work together to identify positives and negatives of procrastinating; toward the goal of engaging you with the skill and practice of staying focused and on task.

While completing this section you will learn and implement skills to reduce procrastination.

• You will learn how to apply new problem-solving skills to planning as a first step in overcoming procrastination; for each plan, you will learn how to break it down into manageable time-limited steps to reduce the influence of distractibility.
• You will learn how to apply new cognitive restructuring skills to challenge thoughts that encourage the use of procrastination (e.g., “I can do this later” or “I’ll finish this after I watch my TV show”) and embrace thoughts that encourage you to take action and complete tasks.
• You will be assigned homework, and be asked to accomplish identified tasks without procrastination using the techniques learned in therapy.
• We will review your progress and I will provide corrective feedback toward improving the skill and decreasing procrastination habits.

Other Objectives