Office management of attention-deficit/hyperactivity disorder (ADHD) differs in many important ways from ADHD management conducted in a research environment. In clinical trials, treatments and eligible patients are selected in advance by committees, patients are randomized to different management strategies, and both clinicians and patients are blinded to the treatments. In general, one treatment variable is tested at a time. Dosage adjustments are usually made according to the re search protocol rather than according to patient response. Results are aggregated and presented for an "average" patient.
In the real world of psychiatric practice, we see every patient who comes through the door. We use only active treatments, and we persist until we find the best one for a particular patient. Be cause we are dealing with complex hu man beings, who often have other coexisting illnesses, we examine every aspect of their lives to find the best possible combination of therapeutic options. We treat individuals, not averages, and must adjust the treatment to the unique needs and responses of each patient. In this article, I will share what I have learned about optimal office management of adolescents and adults with ADHD.
A FUNCTIONAL DEFINITION
Our understanding of ADHD and its treatment was changed by a 2004 study from the New York University Child Study Center.1 Investigators tested the hypothesis that children with ADHD would experience significant improvements in functioning while taking methylphenidate combined with intense, multidisciplinary psychosocial treatment or with attention control training, compared with methylphenidate alone. In addition, investigators hypothesized that compared with children taking only methylphenidate, more children receiving multidisci plinary treatment plus methylphenidate could have their dose of medication lowered or could even dis continue methylphenidate treatment.
A total of 103 children aged 7 to 9 years who were free of conduct and learning disorders and who were documented responders to short-term methylphenidate treatment were randomized to receive methylphenidate alone; methylhenidate plus an intensive multimodal treatment that included parent training and counseling, social skills training, psychotherapy, and academic assistance; or methyl phenidate plus attention control treatment. During the 2-year course of the study, the investigators were unable to demonstrate that combination treatment was as sociated with superior functioning. Combination treatment did not allow discontinuation of methyl phenidate treatment; the study failed to demonstrate significant benefit from adding an ambitious psy chosocial intervention to the regimen. Significant benefits from methylphenidate persisted for 2 years.1
The findings have led to the relatively new concept that ADHD is not a disorder characterized by deficits of effort, character, willpower, brain ac tivity or size, or integrity. Neither is it caused by poor parenting skills or by diminished executive function, self-control, neurotransmitter levels, or intelligence. A newer, functional definition tries to understand ADHD as a genetically based neurologic disorder characterized by difficulties in engaging on demand in work, school, or per sonal situations. This difficulty in be-ing engaged on demand explains why many patients with ADHD seem to function very well in some situations but are distracted and disorganized in others.
Unfortunately, school and work environments require the ability to engage on demand, and these are the environments in which people with ADHD often perform poorly. This disparity in attentiveness in different situations often leads parents and employers to make a moral judgment that ADHD represents a failure of will, effort, or self-control. Our new understanding that ADHD is a genetically based neurologic disorder challenges this view. It also sheds light on the management strategies that are most likely to help these patients. Because ADHD is a neu rologic condition, we should not expect behavioral techniques to be any more successful as a cornerstone of treatment than they would be in the treatment of a fever, for example.
A DIFFERENT NERVOUS YSTEM
People who do not have ADHD have importance-based nervous systems. That is, the importance of a task helps them engage with it immediately, get access to their abilities, and persist with the task all the way to completion. They see the tasks that require completion, arrange them in order of priority, engage in them, and gain access to the skills they need to complete the tasks. Even when a task is more important to an employer, spouse, teacher, or parent than to the person himself or herself, a person without ADHD still manages to accomplish it.
Adults with ADHD report that they cannot remember a single instance in which the importance of a task all by itself ever helped them accomplish it. To a person with ADHD, importance is nothing but a nag. The helping techniques often offered by teachers or parents are importance-based, not interest-based, and do not work for people with the interest-based nervous systems of persons with ADHD.
Every aspect of performance, mood, and energy in a person with ADHD is determined by his or her momentary sense of 4 things: interest, challenge or competitiveness, novelty, and sometimes a sense of urgency brought on by a deadline or impending disaster. In these circumstances, persons with ADHD can engage and produce huge amounts of high-quality work on dead line—as with the student who com pletes weeks of work the night before an examination or the night before a paper is due. Every person with ADHD can recall a lifetime of experiences in which they are "in the zone" and per form at a high level, only to have it slip away when they lose their sense of in terest, challenge, novelty, or urgency. The clinical challenge is to find multiple ways by which people with ADHD can accomplish the tasks of their lives on demand.
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