Attention Deficit Hiperactive Disorders (adhd) Contemporany Approach (adults)

MINISTRY OF HEALTH OF THE REPUBLIC OF MOLDOVA

STATE MEDICAL AND PHARMACEUTICAL UNIVERSITY

“NIVOLAE TESTEMITANU”

FACULTY OF MEDICINE NR. II

Department of Psychiatry

Chief of the Department: Anatolie Nacu, MD, PhD, Professor

License Thesis

ATTENTION DEFICIT HIPERACTIVE DISORDERS (ADHD) CONTEMPORANY APPROACH (ADULTS)

Scientific coordinator:

Jana CHIHAI, MD, PhD, associate professor

Student Name:

Nassem Khateeb (Gr.1045)

Chisinau 2016

Verified:

Data__________________

Scientific Coordinator: dr. Chihai Jana, PhD, associate prof.

Semnătura ____________

“Recommended for approval”

At meeting od Psychiatry, Narcology, Medical Psychology Department

Protocol nr.____________from________________

Head of the Department prof. Anatol Nacu

ABSTRACT

Attention deficit hyperactivity disorder (ADHD) is increasingly recognized as a legitimate adult diagnostic category. Yet the nature of and comorbidities and adaptive impairments associated with adult ADHD have received little scientific investigation. Present diagnostic criteria for ADHD are formulated primarily according to behavior in childhood, based on age inappropriate and impairing levels of hyperactivity, impulsivity and inattention. Other symptoms, such as mood instability and frustration intolerance, are not included in current criteria for ADHD, but are very prevalent in this patient group. ADHD is often co morbid with alcohol and substance abuse and other psychiatric disorders, in particular anxiety and personality disorders. Moreover, adults with ADHD displayed greater self-reported psychological maladjustment, more driving risks (speeding violations), and more frequent changes in employment. Multiple marriages were more likely in the ADHD group as well.  As ADHD is associated with changes in brain function mediating different aspects of neuropsychological functions, assessment of those functions is important to understand the symptom patterns and to develop targeted treatment programs.

The aim of this study is to assess knowledge on ADHD in adults and to show multidisciplinary intervention and treatment programs.

This study could lead to recommendations for the improvement of the quality of life for adults suffering of ADHD and to serve as theoretical bases for professionals working with ADHD.

Keywords: ADHD, treatment, approach, adults

CONTENTS

ABBREVIATIONS

DSM-V – 5th edition of Diagnostic and Statistical Manual of Mental Disorders

ICD -10 – 10th revision of the International Statistical Classification of Diseases and Related Health Problems.

WHO – World Health Organization

ADD – Attention Deficit Disorder

ADHD – Attention Deficit Hyperactivity Disorder

CBT – Cognitive Behavioral Therapy

INTRODUCTION

Topicality of the Issue

Many people have heard of ADHD. It may make you think of kids who have trouble paying attention or who are hyperactive or impulsive. Adults can have ADHD, too. About 4% to 5% of adults have it. But few adults get diagnosed or treated for it.

Every adult who has ADHD had it as a child. Some may have been diagnosed and known it. But some may have not been diagnosed when they were young and only find out later in life.

While many kids with ADHD outgrow it, about 60% still have it as adults. Adult ADHD seems to affect men and women equally.

If you have adult ADHD, you may find it hard to:

Follow directions

Remember information

Concentrate

Organize tasks

Finish work on time

This can cause trouble in many parts of life – at home, at work, or at school. Getting treatment and learning ways to manage ADHD can help. Most people learn to adapt. And adults with ADHD can develop their personal strengths and find success.

If you have ADHD, you can have trouble with:

 Anxiety

 chronic boredom

 delay chronic forgetfulness

 Depression

 trouble concentrating when reading

 anger control problems

 Problems at work

 Impulsiveness

 low tolerance for frustration

 Low self-esteem

 Mood swings

 poor organizational skills

 delay

 Relationship problems

 Substance abuse or addictionThese may affect you a lot, or they may not bother you much. They can be problems all of the time or just depend on the situation.

No two people with ADHD are exactly alike. If you have ADHD, you may be able to concentrate if you’re interested in or excited about what you’re doing. But some people with ADHD have trouble focusing under any circumstances. Some people look for stimulation, but others avoid it. Plus, some people with ADHD can be withdrawn and antisocial. Others can be very social and go from one relationship to the next.

Adults With ADHD may have:

A history of not doing well in school and underachieving

Gotten in a lot of trouble

Had to repeat a grade

Dropped out of school

Get more speeding tickets, have their license suspended, or be involved in more crashes

Smoke cigarettes

Use alcohol or drugs more often

Have less money

Say they have psychological trouble like being depressed or have anxiety

Adults with ADHD are more likely to:

Have more marital problems

Get separated and divorced more often

Have multiple marriages

Problem of the research: ADHD contemporary approach in adults and alternatives of treatment .

Object of the research – ADHD in adults.

Subject of the research – the persons suffering from ADHD and multidisciplinary treatment to increase the quality of life.

Goal of the research:

To assess knowledge on ADHD in adults and to show multidisciplinary intervention and treatment programs.

Objectives of the research:

Review the specialised literature related to ADHD (December 2014 – May 2015);

Analyse the context of ADHD at the international level (December 2014 – March 2015);

Select the models for multidisciplinary intervention in ADHD (January-March 2016);

Process the results and formulate conclusions (March-May 2016);

The rationale for the research is enhanced by:

the growing frequency of the disorder;

the impact on the quality of life

the outspread of the disorder among adults;

HYPOTHESIS:

Most adults with ADHD are bringing the diagnostic from their childhood. Being untreated in the childhood, adults with ADHD meet different difficulties in their life and the quality of their life is suffering. Using multidisciplinary approach in the treatment of adults with ADHD may increase the quality of life.

Research methods, procedures and techniques:

Study and analysis of the scientific literature;

Study of different treatment approach;

Qualitative processing of the results.

The importance of the research – the investigation of different treatment approaches in ADHD in adult life will give the possibility for many people to increase their quality of life.

The practical value of the research – the identification of the multidisciplinary approaches makes it possible to develop a set of therapeutic measures for complex approach to the patients.

Key-terms:

ADHD, treatment, approach, adults.

CHAPTER I. ADHD: general overview

1.1. ADHD according to DSM – V

The American Psychiatric Association published DSM-V in 2015 and it is the first major revision to the diagnostic manual for psychiatric disorders since 1994.  In DSM-V, ADHD is included in the section on Neurodevelopmental Disorders. It was not grouped with the disruptive behavior disorders.  This change reflects the way ADHD is currently understood.
A common problem of the ADHD diagnostic criteria was that the main symptoms reflect how the disorder appears in school age children and does not capture how it presents in teenagers and adults.  Because of this, different symptom sets should be developed for different age groups. So, the new diagnostic criteria essentially retain the same symptoms as before.

The inattentive symptoms are:

fails to give close attention to details or makes careless mistakes in schoolwork, work, or during other activities
has difficulty sustaining attention in tasks or play activities

does not seem to listen when spoken to directly

does not follow through on instructions and fails to finish school work, chores, or duties in the work place

has difficulty organizing tasks and activities

avoids or is reluctant to engage in tasks that require sustained mental effort
loses things necessary for tasks or activities

is easily distracted by extraneous stimuli

is forgetful in daily activities

The difference from DSM-IV is that all symptoms are followed by examples of different ways they may show up, including ways they would appear in teenagers and adults.  Although the symptom list remains the same, the inclusion of developmentally appropriate examples should help clinicians evaluating teenagers and adults.

The hyperactive-impulsive symptoms are:

fidgets with or taps hands or squirms in seat

leaves seat in situations when remaining seated is expected

runs about or climbs in situations where it is inappropriate

unable to play or engage in leisure activities quietly

is "on the go" acting as if "driven by a motor" talks excessively

blurts out answers before questions have been completed

has difficulty awaiting turn interrupts or intrudes on

These are only insignificant modified versions of the hyperactive-impulsive symptoms from DSM-IV.  However, the new DSM-V generally includes developmentally appropriate exemplars of these symptoms in tenagers and adults. 

To possibly warrant a diagnosis of ADHD, teenagers than 17 must have minimum 6 of 9 inattentive and/or hyperactive impulsive symptoms. It is the same same number as was required in DSM-IV. For individuals 17 and above, however, only 5 or more symptoms are needed. This change was made because of the reduction in symptoms that tends to occur with increasing age.  The explanation for this change is that a slightly lower symptom threshold is sufficient to make a reliable diagnosis in adults. As in DSM-IV, the symptoms have to be present for minimum 6 months to a degree that is judged to be inconsistent with an individual's developmental level.

In DSM-IV, a sufficient inattentive and/or hyperactive impulsive symptoms is only the initial criteria that must be met for ADHD to be diagnosed.  Additional diagnostic criteria, and modifications that have been made to these, are presented below.

In DSM-IV, the age of onset criteria was "some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years."  This reflected the view that ADHD emerged relatively early in development and interfered with a child's functioning at a relatively young age. In DSM-V this has been revised to "several inattentive or hyperactive-impulsive symptoms were present prior to 12 years."  Thus, symptoms can now appear up to 5 years later.  And, there is no longer the requirement that the symptoms create impairment by age 12, just that they are present.

The rationale for the older age of onset is that research published since DSM-IV did not identify meaningful differences in functioning, response to treatment, or outcomes in individuals whose symptoms were present at younger vs. older ages.  However, there is also no longer the requirement for symptoms to cause impairment.  This combination – older age of onset and removing the impairment requirement – is clearly more lenient.

In DSM IV, the symptoms were required to cause a disturbance in at least two settings. Thus, not only the symptoms must be evident in more than one frame, for example, both school and home, but had also to undermine the child's functioning in multiple settings. DSM-V has changed this to "inattentive or hyperactive more-impulsive symptoms is present in two or more settings." Thus, the symptoms should only be evident in more than one context, but should not affect the functioning of an individual in several contexts.

This is also more permissive.

DSM-IV is required "clear evidence of clinically significant impairment in social, academic, or at work." This was changed to "… evidence that symptoms interfere with or reduce quality, social, academic, or occupational functioning." I think this is a significant change. In DSM-IV, individuals could meet the criteria symptom, that shows at least 6 of 9 inattentive and / or symptoms hyperactive-impulsive and not be diagnosed if symptoms were not considered to be sufficiently affect. The request is a clinically significant deterioration bar higher than requiring symptoms "..interfere or reduce quality" performance of an individual in important areas of life. In fact, it is difficult to imagine how it might show symptoms sufficient to justify possibly diagnosis without this interfering with someone's social, professional or academic functioning.

How this change is interpreted by physicians will be very important. Suppose a student appears to have the potential to earn all A in school. If ADHD symptoms lead to student receiving A and B, is that enough interference for the student to be diagnosed with ADHD? This is the kind of judgment that all professionals involved in the diagnosis of ADHD will need to make the DSM-V does not provide clear guidance on this issue.

As the above suggests, eliminating the need for "clinically significant impairment" may make it easier to meet the diagnostic criteria for ADHD complete and thus increase the percentage of people who qualify for the diagnosis. I wish that I understood the rationale for this change, but there is no explanation provided on this website DSM-V.

As in DSM-IV, endpoint is to determine an individual ADHD symptoms are not better represented by another mental disorder. In DSM-IV, this was said: "The symptoms do not occur exclusively during pervasive development disorders, schizophrenia or other psychotic disorder and are not better accounted for by another mental disorder." This was changed to "The symptoms do not occur exclusively during a schizophrenia or other psychotic disorder and are not better accounted for by another mental disorder." So, what has changed is that pervasive developmental disorder not exclude the diagnosis of ADHD. In fact, the DSM-V, pervasive developmental disorder category was renamed "Neurodevelopmental Disorders". However, unlike the DSM-IV ADHD can now be diagnosed in connection with autism spectrum disorders. In the past, ADHD were excluded based on the assumption that ADHD symptoms were always better to explain the child's autism.

In DSM-IV, there were three subtypes of ADHD:

• Type combined for individuals who have shown at least six inattentive hyperactive-impulsive symptoms and 6, in addition to all the other criteria;

• predominantly inattentive type symptoms when sufficient inattentive, hyperactive-impulsive but enough were present; and,

• predominantly hyperactive-impulsive type when hyperactive-impulsive symptoms careless enough, but insufficient inattentive symptoms were present.

In DSM-V have been preserved these categories but are now termed presentation combined presentation predominantly inattentive, and predominantly hyperactive-impulsive change presentationThis wording reflects a desire to move from language more static of "types" to use a terminology better reflects the fluidity and changes in how the disorder can present in the same individual over time.

DSM-V also requires clinicians to specify the level of severity of ADHD a client as either mild, moderate or severe.

Light is limited to cases where there is little, if any, symptoms beyond those needed to make the diagnosis and no more than minor impairment in functioning. In DSM-IV, where it was necessary to clinically significant impairment, those persons can not be diagnosed.

Moderate is simply defined as symptoms or functional impairment between "mild" and "severe". People in this category may not necessarily appear clinically significant impairment and therefore also not been diagnosed in the DSM-IV.

Severe is reserved for cases with multiple symptoms greater than those required for diagnosis, or several symptoms that are particularly severe or marked reduction resulting from symptoms.

DSM-IV had a category called ADHD Not Otherwise Specified (NOS) for individuals who have demonstrated prominent symptoms but did not meet the necessary criteria. In DSM-V, this was changed to other specified ADHD and ADHD studies. The first is used when the full criteria are not met, agonizing symptoms are present or clinically significant impairment in functioning and clinician chooses to send you the full criteria are not met. For example: "Other specified ADHD symptoms of inattention insufficient." Not ADHD administering the same circumstance except that the clinician chooses to specify why the criteria are not met complete and more specific diagnosis is not possible.

DSM-V are defined diagnostic criteria for ADHD, but gives no specification for how clinicians should obtain information necessary to determine whether these criteria are met. This was true for DSM-IV and applies to all disorders in DSM. There also continues to be no recommendation for any specific diagnostic test that should be used routinely.

Thus, as before, ADHD remains a clinical judgment that physicians are based on information obtained using methods that choose to obtain it.

1.2 Diagnosis of ADHD

Even if there is no single medical test, physical or genetic ADHD diagnostic evaluation can be provided by a mental health professional or physician, which gathers information from multiple sources. These sources include ADHD symptom checklists, rating scales standardized behavior, a detailed history of past and current operating and information obtained from family members or significant others who know the person well. Some practitioners will also conduct tests of cognitive ability and academic achievement in order to exclude a possible learning disability. ADHD can not be diagnosed accurately only from brief observations office or simply talking to the person. A person may not always show symptoms of ADHD during the office visit and diagnostician must take a thorough history of the individual's life. A diagnosis of ADHD should include consideration of the possible presence of co-occurring conditions.

Guidelines for the diagnosis of ADHD is provided by the American Psychiatric Association Diagnostic and Statistical Manual of mental disorders ,, Manual Fifth Edition (DSM-5). These guidelines set are widely used in research and clinical practice. During an assessment, the clinician will try to determine the extent to which these symptoms apply to an adult now and where were present in childhood. In diagnosis, adults should have at least five of the symptoms present. These symptoms may change over time, so adults can fit different presentations since they were children.

DSM-5 lists three presentations of ADHD predominantly inattentive, hyperactive-impulsive, and combined. The symptoms for each are adapted and summarized below.

ADHD inattentive descrition

 fails to give close attention to details or makes careless mistakes

 Has difficulty sustaining attention

 There seems to listen

 strives to follow instructions

 Has difficulty with organization

 avoids or dislikes tasks requiring sustained mental effort

 losing things

 Is easily distracted

 Is forgetful in daily activities

ADHD hyperactive-impulsive description

 Act as if driven by a motor; in adults they often feel as if they are driven by a motor

 excessive Talks

 Nervousness or feet or squirms hands Chair

 Has difficulty remaining seated

 Runs about or climbs excessively in children; extreme agitation in adults

 Difficulty engaging in activities quietly

 Blurts answers before questions have been completed

 difficulty waiting or taking turns

 interrupts or intrudes upon others

ADHD combined description

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

A diagnosis of ADHD is determined based on the number and severity of symptoms, duration of symptoms and the degree to which these symptoms cause a reduction in various areas of life such as home, school or work; with friends or relatives; or in other activities. Likely to meet diagnostic criteria for ADHD without any symptoms of hyperactivity and impulsivity. The doctor must determine whether the symptoms are caused by other conditions, or are influenced by co-existing conditions. Several of the symptoms must have been present before the age of 12. This generally requires confirmation by a parent or other informant. It is important to note that the presence of significant impairment in at least two major settings of human life is essential for the diagnosis of ADHD. Failure refers to how ADHD interferes with an individual's life. Examples of impairment include losing a job because ADHD symptoms, conflict and excessive suffering in a marriage, entering into financial trouble due to impulsive spending, failure to pay bills on time or be put on probation academic college notes due in crossing. If the individual has a range of ADHD symptoms, but they do not cause a significant reduction, he / she may not meet the criteria to be diagnosed with ADHD as a disorder clinic.

There are many websites about ADHD, offering different types of questionnaires and lists of symptoms. Most of these surveys are not standardized and scientifically validated and should not be used to self-diagnose or to diagnose others with ADHD. A valid diagnosis can be provided only by a qualified professional licensed. Adult ADHD diagnostic evaluation should be performed by a licensed mental health professional or a physician. These professionals include clinical psychologists, physicians (psychiatrist, neurologist, family doctor or other physician) or clinical social workers. Whatever type of professional is chosen, it is important to provide training and experience in working with adults with ADHD. Often the professional knowledge and experience on adult ADHD is more important to obtain an accurate diagnosis and an effective treatment plan than the type of professional degree. Qualified specialists are usually willing to provide information on their education and experience with adults with ADHD. Refusal to provide such information in response to reasonable requests should be regarded with suspicion and may be an indicator that the individual should seek a professional different.

Most adults who need an evaluation for ADHD show significant problems in one or more residential areas. The following are some of the most common problems:

 inconsistent performance in jobs or careers; loss or quitting jobs frequently

 chronic stress and worry due to failure to achieve the objectives and meet the responsibilities

 The limited capacity to manage daily responsibilities, such as completing chores, maintenance activities, pay bills or organizing things

 history of poor academic and / or career

 Relationship problems because no tasks

 Forgetting important things or getting upset easily over minor things

 chronic and intense feelings of frustration, guilt or blame

A qualified professional can determine if these problems are caused by ADHD, another cause or combination of causes. Although some ADHD symptoms are evident from early childhood, some people might not occur until significant problems later in life. Some very bright and talented, for example, are able to compensate for their ADHD symptoms and no significant problems occur until high school, college or pursuing their careers. In other cases, parents may have provided a highly protective, structured and supportive, minimizing the impact of ADHD symptoms until the person began to live independently as a young adult.

Most people are a bit nervous and apprehensive about being evaluated for any type of condition such as ADHD. This is normal and should not stop anyone trying to obtain an evaluation if he / she has significant problems in life and ADHD is suspected. Unfortunately, some of the most common misconceptions about ADHD, such as "appears only in children" or "person is just looking for an excuse," to make people more reluctant to seek help. Many professionals find it useful to review the old report cards and other school records dating back to kindergarten or preschool years. If such records are available, they should be brought to the first meeting. Copies of reports from any previous psychological testing should be also brought to the appointment. For adults who have problems at work, job evaluations should be brought for review if available. Many professionals will ask the individual to complete and return questionnaires before assessing and identifying a spouse or other family member can also participate in some parts of the assessment. timely completion and return of questionnaires will accelerate the evaluation.

Different doctors will vary somewhat in their procedures and testing materials, certain protocols are considered essential for a complete evaluation. These include a diagnostic interview thorough information from independent sources, such as spouse or other family members, DSM-5 checklists symptom scales standardized behavior rating scale for ADHD and other types of psychometric tests deemed necessary by clinician. These are discussed in more detail below.

The single most important part of a comprehensive ADHD assessment is a structured or semi-structured interview, which provides a detailed history of the individual. The interviewer asks a series of pre-determined, standardized questions in order to increase the reliability and reduce the risk that a different interviewer would come up with different conclusions. The clinician covers a wide range of topics, discuss relevant issues in detail and follow-up questions to ensure that all areas of interest are covered. The assessor will review the diagnostic criteria for ADHD and determine how many of them apply to the individual, both now and in childhood. The interviewer will further determine the extent to which these symptoms ADHD interferes with the individual's life.

The evaluator will also conduct a detailed analysis to see if that can resemble other psychiatric disorders frequently coexist with ADHD or ADHD are present. ADHD rarely occurs alone, and research has shown that more than two thirds of people with ADHD have one or more co-existing conditions. The most common include depression, anxiety disorders, learning difficulties and substance use disorders. Many of these conditions have symptoms that may mimic ADHD symptoms, and can actually be mistaken for ADHD. A full evaluation includes screening for co-existing conditions. When one or more coexisting conditions are present with ADHD, it is essential that all are diagnosed and treated. Failure to treat coexisting conditions often lead to failure in treating ADHD. And especially when ADHD symptoms are a secondary consequence of depression, anxiety or some other mental disorders, inability to detect this can result in unfair treatment for ADHD individual. Sometimes, ADHD treatment will eliminate the other disorder and the need to treat ADHD independent. The clinician should inquire about the person's health history, going back to childhood development, academic and work experience, driving history, drug and alcohol abuse, family and / or civil life and social history. The examiner will look for patterns that are typical in people with ADHD and also trying to determine whether factors other than ADHD can cause symptoms that look like ADHD.

It is also essential for the clinician to interview one or more independent sources, usually a significant other (spouse, family member, partner or parent) who knows the person well. This procedure is not to question the honesty of the person, but rather to gather additional information. Many adults with ADHD have a poor memory or spots of their past, especially from childhood. They can recall specific details were given but forget diagnoses or problems they encountered. Thus, the clinician can ask the individual to be evaluated parents fill out a profile description retrospective ADHD childhood behavior. Many adults with ADHD may have also limited awareness of how ADHD-related behaviors cause problems for them and have an impact on others. If married couples or cohabit, it is advantageous for the clinician to interview the couple together to review the symptoms of ADHD. This procedure helps non-ADHD spouse or partner develop an accurate understanding and empathic attitude regarding ADHD symptoms impact on the relationship, setting the stage for improved relations after the diagnostic process has been completed. Where it is not possible to interview loved ones, having them complete list of symptoms is a good alternative. Many adults with ADHD can feel deeply frustrated and embarrassed by the ongoing problems caused by the disorder. It is very important that the person being evaluated discuss these issues openly and honestly and not hold back information because of feelings of shame or fear of criticism. Quality assessment and accurate diagnosis and treatment recommendations will be largely determined by the accuracy of information provided to the examiner.

rating scales and additional testing

A full assessment may include one or more standardized behavior rating scales. These questionnaires conduct research using people with ADHD compared to those of people without ADHD. Scores on scales rating are not considered diagnostic for themselves, but serve as an important source of objective information in the evaluation process. Most clinicians ask the individual being assessed and the other to complete these significant scale assessment of the individual.

Depending on the individual, and issues addressed, additional psychological, neuropsychological tests or learning disabilities can be used as needed. They do not diagnose ADHD directly but can provide important information about the ways in which ADHD affects individual. Testing can also help determine the presence and effects of co-existing conditions. For example, in order to determine whether the individual has a learning disability, the clinician will usually a test of intellectual ability and academic achievement test.

medical examination

If the person assessed has not had a recent physical exam (within 6-12 months), a medical examination is recommended to rule out medical causes for symptoms. Some medical conditions such as thyroid problems and seizures, may cause symptoms that resemble ADHD symptoms. A medical examination does not confirm ADHD, but it is extremely important in helping to rule out other conditions or problems.

Towards the end of the evaluation clinician will integrate information that was collected through various sources, complete a written summary or report, and provide individual and family opinions diagnosis on ADHD, as well as other psychiatric disorders or learning disabilities that may have identified during the evaluation. The clinician will review treatment options and assist individuals in planning a course of appropriate medical and psychosocial intervention.

1.3 Treatment in ADHD

If the doctor that and adult has ADHD, he should work together with the patient to make a treatment plan just for him/her. Treatment plans can include medicine, therapy, education or learning more about ADHD, and getting family support. Together these things can help the patient to find new ways to do things that can make day-to-day life easier. That can make the patient feel better in general and feel better about him/her.

Making sure that the patient is getting fully checked by a doctor is important. That’s because people with ADHD often face other conditions, too. They may also have a learning disability, anxiety or another mood disorder, obsessive compulsive disorder, or a dependence on drugs or alcohol. Knowing the whole picture can make sure you get the best plan for you.

Medications effective for childhood ADHD continue to be helpful for adults who have ADHD.  Various behavioral management techniques can be useful.  Some adults have found that working with a coach, either formally or informally, to be a helpful addition to their ADHD treatment plans.  In addition, mental health counseling can offer much-needed support to adults dealing with ADHD in themselves or someone they care about.  Since ADHD affects the entire family, receiving services from ADHD-trained therapists skilled in Cognitive-Behavioral Therapy can help the adult with ADHD learn new techniques to manage living with ADHD. 

Medications to Treat Adult ADHD

Stimulant Medications. Adults with ADHD are often offered stimulant medications. Studies show that about two-thirds of adults with ADHD who take these medications have big improvements in their symptoms.

Stimulant medications include:

Dexmethylphenidate (Focalin)

Lisdexamfetamine (Vyvanse)

Methylphenidate (Concerta, Daytrana, Metadate, Methylin, Ritalin, Quillivant)

Dextroamphetamine (Adderall, Dexedrine)

Stimulants can be:

Addictive. Stimulants are controlled substances. That means the patient may get hooked on them. Some adults with ADHD have substance abuse problems or had them in the past.

Hard to remember to take. Short-acting types of stimulants (versus long-acting) may wear off quickly. Since people with ADHD can have trouble with forgetfulness, remembering to take them several times a day can be a challenge.

Hard to time. If people choose to stop taking them in the evening, they can have a hard time focusing to do housework, pay bills, help children with homework, or drive. But if they do take them later in the day, they may be tempted to use alcohol or other things "to relax."

Clinicians may also recommend a non-stimulant medication for patient to take, either on its own or with a stimulant. They are:

Atomoxetine (Strattera)

Clonidine (Kapvay)

Guanfacine (Intuniv)

Therapy:

Life coaching. It may help set goals. Plus, it can help learn new ways to stay organized at home and work.

Cognitive and behavioral therapy. It can help with self-esteem.

Relaxation training and stress management. These can lower anxiety and stress.

Job coaching or mentoring. This can help support the patient at work. It can help have better working relationships and improve on-the-job performance.

Family education and therapy. 

About 10 million adults have attention-deficit/hyperactivity disorder (ADHD). There is a significant amount of research on medication treatment for children with ADHD, much less controlled research data has been conducted on medication therapy in adults. As a treatment of ADHD, it has been said that “pills do not substitute for skills.” This means that medication alone is not sufficient to help a person improve his or her problems in areas such as organization, time management, prioritizing and using cognitive aids. However, medication improves attention and reduces impulsivity in adults who have been correctly diagnosed with ADHD. Adults with ADHD may also frequently have other conditions such as depression or anxiety that may require additional treatment.

Medication does not cure ADHD; when effective, it eases ADHD symptoms during the time it is active. Thus, it is not like an antibiotic that may cure a bacterial infection, but more like eyeglasses that help to improve vision only during the time the eyeglasses are actually worn.

Medications that most effectively improve the core symptoms of ADHD seem primarily and directly to affect certain neurotransmitters (brain molecules that facilitate the transmission of messages from one neuron [brain cell] to another). The neurotransmitters involved are dopamine and norepinephrine. Both neurotransmitters appear to play a role in the attentional and behavioral symptoms of ADHD. Practitioners cannot know in advance what drug will work best for a particular patient without trying them. Doctors will use a medication trial to figure out which medicine works best for each individual and at what dosage. The trial usually begins with a low dose that is gradually increased at 3–7 day intervals until clinical benefits are achieved.

Psychostimulant compounds are the most widely used medications for the management of ADHD symptoms in adults as well as children and adolescents. Several long-acting psychostimulants are approved by the Food and Drug Administration (FDA) for the treatment of ADHD in adults and are routinely prescribed. The two stimulants most commonly used, methylphenidate (MPH) and amphetamines (AMP), are regulated as Schedule II drugs by the Drug Enforcement Administration (DEA) because they have a potential for abuse when not used as prescribed by a medical professional. ADHD medications approved for adults include methylphenidate; Focalin, Focalin XR; Concerta; Daytrana; Metadate CD; and the amphetamines, Adderall XR and Vyvanse.

Short-acting preparations generally last approximately 4 hours; long-acting preparations are more variable in duration—with some preparations lasting 6–8 hours and newer preparations lasting 10–12 hours. Of course, there can be wide individual variation that cannot be predicted and will only become evident once the medication is tried.

Since effective longer-acting formulations of stimulants became available, many children, adolescents and adults have found these preferable. Longer-acting medications may cause fewer “ups and downs” over the day and may eliminate the need for taking additional doses at school or during work. Although there is little research on utilizing short-acting and long-acting medications together, many individuals, especially teenagers and adults, find that they may need to supplement a longer-acting medication taken in the morning with a shorter-acting dose taken in the mid to late afternoon. The “booster” dose may provide better coverage for doing homework or other late afternoon or evening activities and may also reduce problems of “rebound” when the earlier dose wears off.

Hundreds of controlled studies involving more than 6,000 children, adolescents and adults have been conducted to determine the effects of psychostimulant medications—far more research evidence than is available for virtually any other medication. There are no studies on the use of psychostimulant medications for more than a few years, but many individuals have been taking these medications for many years without adverse effects. Longer term controlled studies cannot be done because withholding treatment over many years from some patients suffering significant impairments, which is required in a controlled study, would be unethical.

It is crucial for individuals to work with their health care professional to match their needs with the characteristics of the ADHD medication. The process of choosing a medication should involve recognizing the negative side effects of a medication so that the risks and benefits can be adequately weighed in the decision. It is often useful to construct a daily timeline of the needs (both attentional and behavioral) of the adult.

For example, an adult who has severe ADHD symptoms that threaten his/her job may also have difficulty controlling his/her hypertension. In this case, choosing a treatment for ADHD that has a significant effect during the most crucial hours of the work day but does not destabilize the tentatively controlled hypertension will require knowledge of the medications’ actions over time as well as their cardiovascular side effects.

  Monitoring the effectiveness of medication over time is important and may require substantial effort. However, fine tuning of the timing and dosing of the medication can often improve the time-related clinical response. Sometimes the prescribing professional alone may fulfill these functions; sometimes an experienced therapist who is familiar with the adult can provide additional input to help maximize the effectiveness of the medicine. Clinical adjustment may include adding other medications or adding or changing the psychosocial interventions, such as behavioral, cognitive or supportive psychotherapy, coaching, and tutoring.

While improvement of the core symptoms of ADHD is important and crucial, it is often not the only goal of treatment. Rather, improved functioning in the real world (being self-sufficient, having a better quality of life and being able to cope with the demands of daily life) may be the most important outcome for an adult with ADHD. Controlled medication studies in adults with ADHD have begun to track and measure these functional improvements including psychosocial and quality of life functioning. Future controlled long-term medication studies in adults with ADHD are needed to accurately measure the effect of medication on functioning in the workplace, college and interpersonal relationships.

About two-thirds to three-quarters of adults with ADHD will have at least another psychiatric disorder in their lifetime. These other disorders include antisocial personality disorder, anxiety disorders, depressive disorders, bipolar disorders and substance use disorders (SUD). Once you have made diagnoses, the clinician and adult should decide which diagnoses should be treated and in what order.

There is no controlled research on medication therapy in adults with ADHD and coexisting conditions. Treatment decisions of individual medical professional and will be guided by their previous experience therapeutic and clinical extrapolation of clinical experiences of others, and a rational approach, empirical clinical response of the individual.

Significant co-existing conditions are usually treated first, before ADHD, especially if they cause a reduction in clinical and functional disorders and more significant. This is especially true with substance use disorders, severe depression and bipolar disorder, psychosis and homicidal ideation or suicide. It is important to consider how ADHD can be affected by medication for a co-existing disorder both positive and negative, useful and harmful. For example, the treatment of depression with bupropion can also help ADHD. On the other hand, some medications for major depression and bipolar disorder may actually worsen the symptoms of ADHD. SSRIs (selective serotonin reuptake inhibitors), which by themselves do not effectively treat ADHD symptoms directly, appear to be successful in the treatment of individuals who have co-existing depression and taking stimulants, while for ADHD.

It is also important to note that ADHD drugs can affect co-existing disorders. For example, psychostimulants may worsen an untreated anxiety or bipolar disorder. The risk of stimulant abuse is also higher in adults with substance use disorder and are actively using. However, as mentioned above, successful treatment of ADHD tends to decrease the chances of a person developing ADHD eventually a SUD.

Some nonstimulant treatments for ADHD can be treated adequately and simultaneously co-existing disorder along with ADHD. For example, an antidepressant (TCA, bupropion, venlafaxine) can effectively treat depression and ADHD co-existing, and similarly, a TCA or venlafaxine can successfully treat ADHD and anxiety co-existing.

CHAPTER II. MULTIDISCIPLINARY APPROACH OF INTERVENTION IN ADHD IN ADULTS

2.1. Cognitive behavioral therapy

Cognitive-behavioral therapy refers to a type of mental health treatment that focuses on the thoughts and behaviors that occur in the “here and now. This approach differs from traditional forms of psychoanalytic or psychodynamic therapy, which involve recapturing and reprocessing the childhood experiences that may result in current emotional problems. A difference of CBT over these earlier therapies is that its goals and methods are stated clearly, and, therefore, can be measured for each individual.

CBT originated in a melding of cognitive therapy, developed in the 1960s by Aaron Beck and popularized by Albert Ellis, and behavior therapy, developed by B.F. Skinner, Joseph Volpe and others. Beck and Ellis believed that we all have automatic thoughts that occur immediately in response to an event, situation or other stimulus. These thoughts or cognitions may be helpful and lead to positive feelings and effective coping—or they may be negative leading to feelings of depression or anxiety and maladaptive behavior. These negative thoughts are typically based on irrational beliefs or cognitive distortions. Examples include:

all-or-nothing thinking, which gives rise to perfectionism

catastrophizing, believing that it would be a catastrophe if something does or does not occur

selective attention to negative events or outcomes (and overlooking positive outcomes)

personalization, seeing oneself as the cause of some negative external event for which one is not, in fact, primarily responsible

CBT helps to identify these irrational beliefs by challenging and ultimately negating these beliefs through discussion and home exercises, which typically include keeping thought logs.

During many years cognitive therapy has been expanded and tailored for the treatment of depression, and many specific types of anxiety, including generalized anxiety disorder, social anxiety, post-traumatic stress disorder and obsessive-compulsive disorder. The negative behaviors, as well as the negative thoughts, are addressed in treatment (hence the term cognitive-behavioral therapy). Exercises within the session and at home typically involve gradual, systematic exposure to the arousing situations and the development and rehearsal of skills to better manage those situations, as well as challenging the irrational automatic thoughts that may occur. 

CBT is relevant for adults with ADHD in two ways. First, in recent years, CBT programs have been developed specifically for adults with ADHD. Some of these programs aim to help adults overcome their difficulties in everyday executive functions that are needed to effectively manage time, organize and plan in the short term and the long term. Other programs focus on emotional self-regulation, impulse control and stress management. 

Additionally, it has been well established that adults with ADHD are more likely than adults in the general population to suffer from co-existing anxiety and depressive disorders. A large national study found 51% of adults with ADHD suffered from co-morbid anxiety and 32% suffered from co-morbid depression. Thus, treatments that incorporate CBT for these disorders may be quite helpful to many adults with ADHD, even though they are not designed specifically to address the symptoms and impairment associated with ADHD.

Programs that address executive dysfunction fall into the category of cognitive-behavioral therapy because they impart more adaptive cognitions about how to go about planning, organizing, etc. and also impart more effective behavioral skills. An example of an adaptive cognition is the self-instruction to “break down complex or unpleasant tasks into manageable parts.” Examples of behavioral skills are using a planner regularly and implementing a filing system. Positive thoughts and positive behaviors reinforce each other; as the person becomes more effective in managing time, s/he comes to have more positive beliefs and cognitions about the self, and these in turn help to generate and maintain more adaptive behaviors. 

Stimulant and non-stimulant medication has been shown in numerous studies to be effective for treating ADHD in adults. Research thus far shows that CBT can provide benefit whether or not the person is being treated with medication. There have not yet been any direct, head-to-head comparisons of CBT and medication, but clinical experience suggests that they have different effects: Whereas medication helps to control the core symptoms of distractibility, short attention span and impulsivity, CBT is more effective at increasing the habits and skills needed for executive self-management and may also serve to improve emotional and interpersonal self-regulation. 

2.2. Time management in adult ADHD

Many adults may have difficulty with the disorder, both in home and office and feel overwhelmed or blocked. Getting organized can help you in many ways, including:

 Increase Productivity

 serving as a positive role model for your children

 freeing up time spent looking for things

 reduce anxiety

 make more money being effective

 improve your marriage, partnership and other close relationships

One of the hardest things to do when making a change is beginning. positive reinforcement and rewards can motivate the patient to become more organized. Before you begin a task organization, select a reward to give when finished.

The strategy for getting organized

The best approach to learn a complex task is to be divided into smaller steps and steps to address these one at a time. Organizing a physical space can be divided into the following steps:

 select spaces to be organized

 put them in order from easiest to most difficult

 start with the easiest space

 schedule time to work on it

 decide on the reward or incentive to encourage completion of each stage

 divide the space into sections

 work on one section at a time, sorting, discarding, or reorganizing every object in that section until it ends

1. Select a space and estimate / time schedule

The first step is to make a list of all physical spaces that need organizing, numbering the spaces from "easiest to organize" to "most difficult to organize," using a greater number of jobs more difficult. You can post a copy of the list on a bulletin board or refrigerator door, somewhere you can see all the time. Start with the easiest first space to maximize chances of success, and later move on to more difficult locations.

Select the easiest space from the list. Estimate how long it might take to organize it. Choose a schedule to complete the organization of this space. If the estimate is stopped, additional time may be added later. The estimated time is divided into a series of shorter working sessions, 30 to 60 minutes each. If you think would be frustrated or bored 30 to 60 minutes to brief session from 10 to 15 minutes and schedule more sessions. The idea is to start working for a short time that you can experience success without becoming frustrated and overwhelmed. Using a calendar, schedule fairly short sessions organized in the next few days or weeks to complete the task, adjusting the estimate if necessary. Record deadline and the organizing times a day planner.

1. Divide the selected space into sections or centers

 Divide the space you are working on a network and work on a portion of the network at a time. There are a number of ways to divide the space:

 Divide the space into quarters visually or by marking it with masking tape or string.

 Divide the room into sections by dividing function as a clock. Stay in the room door, makes the spot 12:00 to organize first. How to work around the room systematically, organizing the area at 1:00, 2:00, 3:00 and so on until you return to where you started. If this entire room this way is too much, tackle one or two "hours" of the clock during each of the sessions scheduled organization.

 Organizing sections of the chamber functions. Keep all equipment, consumables, papers and other items for a particular function in that area of ​​the room. For example, to organize your home office, ask yourself what functions could be done in the office.

Activities to be performed in your home office:

 read and respond to e-mail

 Internet browsing and making online purchases

 paying bills, doing taxes on income and supplementing various other financial documents

 writing papers and reading professional journals

 putting photos and slides in albums and working on digital images on computer

Camera could be organized into four zones.

 Computer Zone on an office computer, printer, modem, printer and computer supplies, trade catalogs, journals and storage for professional

 Area foto-camera, film, lenses, photo accessories, binders for negatives and slides and photo albums

 financial paperwork Area-file cabinets with financial records, invoices, checks, additional bank cards and Calculator

 Reading Zone a comfortable lounge chair with a lamp that stands a table next to the chair and libraries with books

Draw a picture of the room on a piece of graph paper examines the current arrangement of furniture and plan how to re-arrange the furniture to form the four new areas. Only by planning each zone and anticipating where the items will be stored in the area you move to the next step of work on each area.

2. systematically work on each section

Gather all you have to do the job (like many cans, plastic containers, trash bags, masking tape, markers, crayons and paper, cleaning supplies, labels). Set the timer and start the music selected. Start with three boxes and a trash bag. Label the boxes "Keep here", "go elsewhere" or "not sure." Place all food and food containers remaining empty trash bag. Place dirty dishes or silver in the "go elsewhere" to return to the kitchen when you are finished.

Pick up an item at a time. Decide which box the item belongs and determine if the item is still useful to you. If not, put it in the garbage bag. Put the items saved in the box "hold here" where they belong in the section are now organizing or "go elsewhere" box if they belong to another section or room.

Do not take a lot of time with each item. If it can not quickly decide to keep or discard the item, place it in the "not sure". Continue going through a product until everything was sorted out in the section or timer faded or playlist has ended. Then stop the project for the day. Take out the trash. Take "of elsewhere" box and return those items to their not worry that can not yet be organized homes of its "home" .; just leave them in that section or room for now.

Leave the "not sure" in the room until the completion of sorting all items. Then, close and seal the box with masking tape. Write with a marker a future date three to six months away from the outside of the box. This is the date when it will re-open the box and check the contents. Brand re-open date in your planner day. Place the box in a storage area. When you review items on the day appointed, do one of the following:

• If you were to look in the box during storage element three to six months, then you do not need her. Put it in the trash or give it away.

• If you have searched item or decide now to keep it, find a home for her and put it there.

At the end of each session organization, congratulate yourself on the successful effort and give yourself the reward you have chosen.

3. Finish space organization

Repeat steps for organizing each section until the completion of the space. Congratulate yourself and enjoy a great reward. Move on to the next item in the list of areas to be organized and follow the steps above. Continue to follow the steps until all spaces on the list were organized.

Four things to do with paper:

• garbage or recycle

• refers to someone

• act on it now

• save or file you

You can also reduce the need to make paper in the future by removing your name from mailing lists. Catalog Choice is a website that you can use to unsubscribe from multiple mailing lists catalog and retailers have agreed to honor these requests.

Another way to reduce paper is to use the camera, scanner or phone to take pictures of recipes, notes, newspaper articles or other documents that you want to save, but must be originals; save them to your computer and back up files regularly. You can use folders on your computer to organize these images for easy access and searching. After scanning the paper, recycle.

Every day home or office is bombarded with documents, notes, telephone messages, flyers, coupons, invoices and mail you need to know about. The ticker is a dated filing system that eliminates piles, files and lists clutter your life. The system consists of 43 folders, each labeled for each month (labeled January-December) and marked for each day of the month (labeled 1-31).

Put the current folder months before the files numbered 1-31. Keep these records on demand (such as a folder on the desk stand or kitchen counter). Submit these documents after the file must act upon them. To make this system, always remember to check the files daily.

At the end of each month for the following month moving files to the front and sort the items that are inside that folder in the corresponding numbered files daily.

Try some of the following techniques for neatly storing items and maintaining organization:

 If you do not put things away because you are afraid you will not find them, try storing them in clear containers. Being able to see inside the container will save time.

 Use over-the-door hanging organizer with pockets divided in each room to store things such as office supplies, jewelry, makeup, tapes or CDs, cleaning products, articles pantry items Child Care, gloves, hats and scarves, and craft supplies.

 Keep small items under the bed boxes.Burn place.

 Purchase a high trash to store extra blankets or sheets and out-of-season clothes. Place the can next to the bed, covered with a tablecloth from floor length, and use it as a night stand.

You can spend less time hunting for things by setting up a table or shelf small front door for the items you need when away from home. Place a small container or basket on the table to hold keys, glasses and wallets. Briefcases and backpacks can also be placed there the next morning.

Centers set up to hold similar items and supplies needed to complete a task. Elements of each individual can be placed in any available mobile container, including baskets, tackle boxes, buckets and carts on wheels. This will save time because all the materials needed to complete a project will be in one place. Make a list of centers that they develop and items in each center. Post the list on the bulletin board, so as to easily remember where these items are.

Ways to maintain a newly organized space

1. handy box

Keep a box or basket handy for items that are in place as they clean a room. When you come in out-of-place items, put them in the container. Once you have finished cleaning the room, take a few minutes to put these items in the room itself.

2. At this point

 When you pass an open drawer, close it.

 When you pass a dumpster full, empty.

 When you see an item of clothing on the floor, close it.

 When you see some loose papers, put them in the box file.

3. 10 minutes takeover

Spend 10 minutes each night on a quick pick-up. Take a basket and go through the house and fixing things quickly take you belong. Better yet, get the whole family involved by having them clean up their space each evening before bedtime.

4. Quick clean

 Pick up dropped things.

 Put away what you use.

 Delete a spill as soon as it happens.

5. Only for 15 minutes

This is a great way to start a project you have been putting off.

 Set a timer for 15 minutes.

 focus efforts on one thing for those 15 minutes.

 When the timer goes off, decide whether you can continue for another 15 minutes.

 If you can, set the timer again for the next 15 minutes.

 If you can not simply stop and do the same later in the day or the following day, until you try to finish the project is completed.

6. Decrease before adding

Make a rule for yourself- "always falls before adding" Do not add (purchase) a new item unless decreases (such as any new books or magazines, unless you read and unread books or magazines do not give).

7. Put in place

Whenever there a few minutes to spare, put aside five or 10 items that are not in their proper place. These could be toys that kids have left somewhere, letters that need filing away, or socks that need to be put in the drawer.

8. Toss / donate box

Keep a box or bag in a storage area to collect items to donate. As you see an item you do not want or use it to take immediate donation box. Do not let unwanted or unused objects occupy a valuable space waiting for a periodic dig-out. Place small items in the trash and largest in a storage area for trash pick-up days.

GENERAL CONCLUSION AND RECOMANDATION:

Life can be a balancing act for any adult, but if you find yourself constantly late, disorganized, forgetful, and overwhelmed by your responsibilities, you may have ADD/ADHD. Attention deficit disorder affects many adults, and its wide variety of frustrating symptoms can hinder everything from your relationships to your career. But help is available—and learning about ADD/ADHD is the first step. Once you understand the challenges, you can learn to compensate for areas of weakness and start taking advantage of your strengths.

Adults with ADD/ADHD often have difficulty staying focused and attending to daily, mundane tasks.

Many adults with ADD/ADHD have a hard time managing their feelings, especially when it comes to emotions like anger or frustration.

Hyperactivity in adults with ADD/ADHD can look the same as it does in kids.

Adults with ADD/ADHD are much less likely to be hyperactive than their younger counterparts. Only a small slice of adults with ADD/ADHD, in fact, suffer from prominent symptoms of hyperactivity. Remember that names can be deceiving and you may very well have ADD/ADHD if you have one or more of the symptoms above—even if you lack hyperactivity.

Untreated ADD/ADHD has wide-reaching effects. ADD/ADHD that is undiagnosed and untreated can cause problems in virtually every area of your life.

Armed with an understanding of ADD/ADHD’s challenges and the help of structured strategies, you can make real changes in your life. Many adults with attention deficit disorder have found meaningful ways to manage their symptoms, take advantage of their gifts, and lead productive and satisfying lives.

Adults with ADD/ADHD can benefit from a number of treatments, including behavioral coaching, individual therapy, self-help groups, vocational counseling, educational assistance, and medication.

Treatment for adults with attention deficit disorder, like treatment for kids, should involve a team of professionals, along with the person’s family members and spouse.

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DECLARATION

I hereby declare that the diploma paper entitled ” ADHD contemporary approach” It is written by me and never ever submitted to another university or higher education institution in the country or abroad. Also that all sources used, including those on the Internet, they are stated in the paper with the rules to avoid plagiarism:

all text fragments reproduced exactly, even in his own translation of other languages are in quotation marks and have detailed reference source ;

reformulation of texts written in their own words by other authors hold detailed reference;

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Student: NASSEM KHATEEB ____________________________ (signature)