Cognitive Therapy and ADHD - An Alternative or Adjutant to Drugs ?

From our own adult ADHD group we know that the majority have been prescribed psycho-active drugs, and despite many positive experiences, compliance, side effects and 'toleration' requiring hirer dosing are all reported by those who did not want to continue. No one in our group was directed to pyschological therapeutic regimes, such as cognitive behavioural therapy  (CBT) , relaxation-meditation, hypnosis, music therapy, working memory training, neurofeedback or diet-lifestyle-career councelling.

Low Actual Referral from Physicians to Psychological Therapy

Although some those general practitioners who had referred our participants further to psychological /psychiatric services had mentioned that they believed non drug based regimes would be available, the actual outpatient based handling was limited to gathering the personal history, confirming diagnosis and then going right onto prescribing 'Ritalin'. No alternative was offered and when two of our group had asked senior psychiatrists during such final consultations about alternative non pharma regimes, they were told that nothing was available or that no such route could be funded.

This may not be a surprise because most western physicians now believe that the disease is well managed in both children and adults at the end of one penned line of ink - Rx. There is a magic bullet, They will be cured. Efficacy can be debated in terms of both percent responders and those who do not 're-present' with symptoms. However the patients who are directed down this route may feel that this is an all or nothing because it is culturally accepted that Ritalin and other preparations, "cure" adhd.

Efficacy and the Lost Large Minority of Poorly Managed Patients on Drug Regimes

As the director of the then Glaxo-Smithkline Beecham said " I know that our drugs do not work on up to half of the patients treated, and I want to know which half they do work in" when the science of pharmacogenetics  promised to reveal the genetic markers and biomechanisms which explain 'resistance' , 'tolerance' (re. the specific interpreation of these terms in light of pharmaceuticals) and fast metabolism. Hence patients could be screened for these and hence their low probability for a successful treatment by a particular drug. However so far genetic testing  or biomarker assesment in relation to prescribed pharmaceuticals is limited to 'higher value' and higher risk regimes due to cost constraints and it could be argued an antipathy from Big Pharma who want their drugs prescribed as often as possible and is safe within the patent pending period.

Perhaps our group is quite representative of the adult experience with ADHD Medication in that around 3 in 10 report that drugs did not work, while a further 3 more in each ten (of 20 participants) reported leaving the prescribed regime due to the factors above (side effects, 'tolerance', disturbed compliance, price of medication all played a part for us) . Another 2 participants reported coming off the drugs and having a significant, lasting improvement in concentration and mood.

This last point highlights what we believe should be debated within clinical and social support services. That ADHD is one of those mental diseases which can be 'learned out of'. In the case of the minority who had come off the drug, but felt that they had this lasting benefit, could it be that the drug helped the brain learn new tricks ? Once again, it would not be in the interests of Big Pharma nor general practitioners to have patients leave what is prescribed as chronic and indefinite therapy, and a single piece of paper, single consultation, single referall "cure" from the general practitioners standpoint..

Few Clinical Trials on Alternatives to Medication

There are very few clinical trials of psychological treatments and the author is at this time still trying to consider the value of the results (many are multi-modal and part pharm and not comparitive to the exclusion of pharma)  and to find any reference to trials of CBT on adult adhd, where it may be most appropriate and effective.


Cognitive BehaviouralTherapies (CBT) Engaged by Patients By Accident or Self 'Prescribing'.

Cognitive based therapies have evolved in the post war era as highly effective for those participants who are diligent and receptive. ( Here in lies the compliance issue when compared to simply popping a daily pill when considering clinical trials) They are steadily replacing freudian derived pyschotherapeutic therapies in areas like angst, depression and most of all in stress management, and are seen as an alternative to medication by many psychologists if not so many physicians unfortunetly.

CBT is based on conscious methods and not obtuse routes to making the patient / participant understand the sub conscious nature of many feelings and how these produce often undesirable thought patterns (NAT - negative automatic thought for example). In essence awareness to this phenomena coupled to self 'arrest' of symptoms and situation / emotional analysis techniques are effective in a wide range of 'conditions' such as the above, but also they form the core of Anger Management offered by many services and charities.

It is via this route that several of our group had come into CBT, because their disruptive, impetuous and even violent behaviours lead them to be referred to self accept anger managment courses. The CBT based therapies are aimed at adults due to the quite high level of learning or maturity you might say, which is required in contrast to that which could be expected in children. However CBT is very much a part of many parental -strategy -therapies for ADHD too, and it is likely that an increasing body of work will arise in this area due to the quite widely held opinion that drugging children is always wrong for such ailments.

It would be interested to look at longditudinal studies or comparitive efficacy reviews where CBT was compared to both just ADHD medication and the combination, but the issue of compliance will still be there - how many complete the course which can be many hours over many weeks or months, followed by the accompanying need to really learn and practice the techniques and tools whcih are taught.

For our group we can report that participants had positive experiences with Anger Managment in particular and that CBT was something they were interested in terms of their wider set of symptoms and as an alternative to the drug regime and its inadvertent side effects and long term quiestion mark.





Further Reading

http://www.chadd.org/Understanding-ADHD/Parents-Caregivers-of-Children-with-ADHD/Symptoms-and-Causes/Researchers-on-ADHD-Research.aspx

http://www.additudemag.com/adhd/article/912.html

http://www.help4adhd.org/en/treatment/behavioral/WWK21

http://www.helpforadd.com/mta-study/

ADHD and Meta Symptoms / Spin Out Life Problems

It is well documented that ADHD in adulthood has wide ranging, detrimental effects on the person whom is afflicted and their relationships. For example some authors quote research which shows that the rate of divorce where one partner is a sufferer, is double the average for the population.

In fact within our group it was often the symptoms which exbibited in failed relationships, disrupted careers, substance abuse and petty criminality which lead eventually to the diagnosis of ADHD in adulthood. For our group the majority of participants are in that category, with a few more being 'rediagnosed' having had a childhood period of treatment or awareness, the supposition that they had grown out of their behaviour was clearly wrong.

Stress is both a result of the uncontrolled disorder, and of course stressful situations exacerbate the individual's negative experience in their often poor ability when tackling the challenge and resulting reduced capacity to create positive or acceptable outcomes and indeed sensible compromises.

ADHD then lowers the threshold often to what is perceived or experienced as stressful. If we define stress as always a negative feeling, while stimulation may be both this and positive..... and do not take the route to discussing what stress is, for better or worse, as some authors do. Stress then by our definition, is an unwanted feeling caused by some external  stimulus (or you could argue a largely internal negative course of thinkiing or actions) . The normal or average person in a western society will learn to tackle this with different methods, including of course removing the source or seeking outside help. Often what is considered a mature tackling method will be to assert an objetcive approach and try to detach emotions from the stimulus and thus reduce stress in fact, and aid successful cognitive solutions.

A large minority of participants in our group have attended or been 'prescribed' or even legally bound to take part in courses which can be categorised into:   anger management, assertiveness, coping with stress. The key route for improvement of behaviour in all of these is the 'mature-assertive' approach. This is about recognising the emotional element in interpreting and acting on stimuli and situations, and breaking the link to automatic, often semi subconscious response and most often laiden with unduly negative interpretations.

Responsiveness to this type of course amongst our group is varied from no effect recalled to very strong positive outcome in that new tackling methods were learnt. It is impossible to draw conclusive, quantitative proof that these type of courses and their common approach to breaking automated, negative behaviours, from the discussions in our group. However qualitatively we can propose that psychologists and physicians should recommend a specific type of course or adopt this approach more in their own therapy. We do this, from sound ethical ground
because the course can do no harm, and the potential for positive influence is very high.

This brings us back to the contention that the use of psychomodulatory medication , most often Ritalin today, is onl;y part of 'curing' adhd ie reducing symptoms to a stage where the individual does  not have adverse effects on their own lives and those around them. Alternatively we can propose that medication is not the best route to tackling the disease because there is no long term clinical studies which assess lifetime use of these drugs, to ascertain if they become tolerated (ie reduced effect over time ) or if side effects become more prevalent.Or indeed the ethical question that individuals become normalised to a level of functionality in society, and in fact are not realising their potential in life.

The Author's Conclusion
Courses with the approach described above can really only help people to have more insight to their feelings, their thoughts or lack of them, and what they can do about them in terms of both the base symptoms of the disease and their abilities in tackling stressful situations and life shaping decision making.

Looking for Positive Sides from ADHD - Affliction or Blessing ?

Our group have never really touched in any depth or involvement upon the concept that ADHD is actually a positive force in enabling creativity. As one author recently described, perhaps we should look to extenuate the positive sides of hyper activity and question our education systems for not embracing the symptoms or offering alternative appraoches to teaching kids who are diagnosed ADHD. Once again it is a contention that there is mass over diagnosis too, and this is largely attributable to classroom 'misbehaviour'. Are we actually denying all children enough opportunities for creative outlet, and more captivating methods of teaching as we rush towards aligning our western school systems to a 'Three R's' teach and test system in order to score higher on PISA tests, and to marketise the public education system?

Some authors and commentators point to ADHD being purely a facit of modern conformity in an increasingly economically conservative education system, a good review here at collective-evolution, that is to say a system which the New Right have laden with testing in the 3 Rs which uses up more time and focus, to the cost of more creative and abstract activities in the classroom - teaching having become increasingly aimed at making and rewarding sqaure pegs in square holes. The trouble with all the New Right's (neo conservative's) agenda in using the PISA test as a benchmark for the relative success of schooling is that Finland leads the way, and does most all things in a very different way than that which the New Right would like. Much of the neo conservative agenda is driven by ideology as vehemntly as Stalinism, blind to opposition and running rough shod over educational bodies, pedagogical experts and the teachning profession.

It is ironic of course that much of the new wealth creation in the west then which has fuelled the rise of the neo conservative nouveau super riche and affluent "MBA middle class", have come from highly creative and entrepreneurial sources. The perfect example being Steve Jobs, whose legacy is now one of the world's biggest five Stock Market listed companies and employers. He certainly seemed to be very selective in what he chose to focus on, and what advice or criticism he allowed to penetrate his armadillo like ego -skin. You could  look at all the stock market stars of the post internet bubble, Google, Facebook, Amazon and many small to medium size Gazelle companies, and consider that the key force in establishing their critical mass in the market has been creativity and not conforming to conventions and rigid ways of practicing business development. The companies may have become sqaure in their need to go to IPO and report quarterly accounts and strategy to the "Street" but their fundamental value propositions were forged by highly creative individuals and often their R&D is stil true to this, so as not to kill the golden-goose as so  many take overs and floatations have done before.

Also the Leadership of for example the UK, come from an academic 'Elite' who had their self confidence, vision and social abilities forged at the most exclusive schools, namely Eaton and Harrow etc, where there pupils are offered a very diverse approach to building society's future leaders - in sports and arts in particular, and in pupils being ecouraged to be confident in self expression and self determination. Not so popular a theme perhaps in Tory circles,  of what state schools could do in order to create more success oriented individuals and see the individuals amongst the PISA orientated testing and statistics.

Politics aside, the opposite proposition is that ADHD for the vast majority is more an affliction than a gift, and that the disruptive patterns of brain activity and resulting behaviour are more destructive for the majority of individuals. just as very very few autistic children become world leading arcitechts or musicians, a small number of ADHD diagnosed kids go on to have truly exdceptionally successful lives. You can argue that of course, education fails them. And that is the crux of the matter which we will blog on again after som further discussion at our next group meeting.