Anthony L. Rostain, M.D., M.A.

Transcription

1 Evidence-Based, Manualized, Group & Individual Psychosocial Treatments for Adult ADHD: Theory and Practice ADHD Worldwide First Joint Meeting Tel Aviv, Israel Feb 27-28, 2013 Anthony L. Rostain, M.D., M.A. Professor of Psychiatry and Pediatrics Perelman School of Medicine, University of Pennsylvania Director, Adult ADHD Treatment and Research Program, Penn Behavioral Health (UPHS) Director, Developmental Neuropsychiatry Program, The Children s Hospital of Philadelphia

2 Disclosures Consultant, advisory boards Shire Pharmaceuticals Alcobra, Ltd BioBehavioral Diagnostics Royalties Routledge Press

3 Collaborators Alexandra Philipsen, M.D. (University of Freiburg) J. Russell Ramsay, Ph.D. (Perelman School of Medicine, University of Pennsylvania Mary Solanto, Ph.D. (Mount Sinai School of Medicine) Susan Sprich, Ph.D. & Steven Safren, Ph.D. (Massachusetts General Hospital, Harvard University)

4 Objectives for Lecture At the end of this talk, attendees will be able to: (1) Cite major findings from the published literature on psychosocial interventions for adult patients with ADHD (2) Describe similarities and differences among two group and two individual-focused interventions

5 Published Psychosocial Treatment Studies (N=17) Ratey et al. (1992) treatment failures Wiggins et al. (1999) educational gp (TFA) Wilens et al. (1999) chart review CBT/meds Hesslinger et al. (2002) DBT group Philipsen et al (2007) DBT-group, multi-site replication Stevenson et al. (2002, 2003) CRP group treatment & self-directed CRP Weiss et al. (2006) PST & meds Rostain & Ramsay (2006) CBT & meds Ramsay & Rostain (2011) CBT only Solanto et al. (2008, 2010) CBT gp focused on EFs Virta et al. (2008, 2010); Salakari et al. (2010) CBT gp rehabilitation/ 6 mo. fu Bramham et al. (2009) CBT group Safren et al. (2005, 2010) CBT/meds v. meds only; CBT v. relaxation

6 Published Psychosocial Treatment Studies Ratey et al. (1992) treatment failures Wiggins et al. (1999) educational gp (TFA) (N=17) Wilens et al. (1999) chart review CBT/meds Hesslinger et al. (2002) DBT group Philipsen et al (2007) DBT-group, multisite replication Stevenson et al. (2002, 2003) CRP group treatment & self-directed CRP Safren et al. (2005, 2010) CBT/meds v. meds only; CBT v. relaxation Weiss et al. (2006) PST & meds Rostain & Ramsay (2006) CBT & meds Ramsay & Rostain (2011) CBT only Solanto et al. (2008, 2010) CBT gp focused on EFs Virta et al. (2008, 2010); Salakari et al. (2010) CBT gp rehabilitation/ 6 mo. fu Bramham et al. (2009) CBT group

7 Harvard (MGH) Model (Safren et al., 2005) sessions; individual 16 active (CBT + meds), 15 control (meds only) ADHD rating scale HAM-D HAM-A CGI Significant improvement with CBT vs control (P<0.01) Depression scores significantly lower with CBT vs control (P<0.01) Anxiety scores significantly lower with CBT vs control (P<0.04) Significant improvement with CBT vs control (P<0.002) Current Symptom Scale Significant improvement with CBT vs control (P<0.0001) 0.98 BDI Trend toward improvement with CBT vs control (P<0.06) 0.77 BAI Anxiety scores significantly lower with CBT vs control (P<0.04) 0.83 Safren et al. (2005). Behavior Research and Therapy, 43,

8 Harvard (MGH) Model (Safren et al., 2010) 12 sessions, individual 43 CBT, 43 relaxation with education ADHD Rating Scale CGI Scores significantly better with CBT vs relaxation (P<0.02) Scores significantly better with CBT vs relaxation (P<0.03) ADHD Current Symptoms Scale Slope of improvement greater with CBT vs relaxation (P<0.001) 0.78 Safren, Sprich et al. (2010). JAMA, 304(8),

9 U Penn Model (Rostain & Ramsay, 2006) 16 sessions, individual N=43 (CBT + meds) BADDS Total CGI CGI-A HAM-D Significant improvement posttreatment vs baseline (P<0.001) Significant improvement posttreatment vs baseline (P<0.001) Significant improvement posttreatment vs baseline (P<0.001) Significant improvement posttreatment vs baseline (P<0.001) Rostain & Ramsay (2006). Journal of Attention Disorders, 10,

10 U Penn Model (Ramsay & Rostain, 2012) 4 13 sessions N=5 BADDS Total Significant improvement pre- to posttreatment (P=0.04) 0.83 BADDS Activation Significant improvement (P=0.03) 0.54 BADDS Attention Trend toward significance (P=0.06) 0.98 Ramsay & Rostain (2012). J Cognitive Psychotherapy: 25:

11 Mount Sinai Model (Solanto, Marks, Mitchell, Wasserstein, & Kofman, 2008) 8 or 12 sessions, group N=30 CAARS-S:L Inattentive symptoms Hyperactive-impulsive symptoms Significant difference vs baseline (P=0.000) Nonsignificant difference vs baseline Inattentive: 1.22 Hyperactive: NS BADDS Total Significant difference vs baseline (P=0.000) 1.57 ON-TOP Significant difference vs baseline (P=0.000) 1.11 Solanto et al. (2008). Journal of Attention Disorders, 11,

12 Mount Sinai Model (Solanto et al., 2010) 12 sessions, group 45 metacog (MC) therapy, 43 supportive therapy (ST) AISRS inattention Pre-post MC Pre-post ST Significantly greater improvements in severity of ADHD inattention symptoms vs control as measured by investigator- and self-report and informant behavioral ratings AISRS Time Management CAARS inattention BADDS Total BRIEF Solanto et al. (2010). American Journal of Psychiatry, 167,

13 U Freiburg Model (Hesslinger et al., 2002) 13 sessions, group 8 active, 7 control ADHD Checklist Treatment group had 1.10 SCL-16 improvement on all scales, including mood and ADHD symptoms, vs baseline 0.66 BDI 0.54 VAS (personal health status) 0.69

14 U Freiburg Model (Philipsen et al., 2007) 13 sessions, group N=66 ADHD Checklist SCL-16 Significant difference vs baseline (P<0.001) Significant difference vs baseline (P<0.001) BDI Significant difference vs baseline (P<0.001) 0.56 VAS Significant difference vs baseline (P<0.001) 1.05 Philipsen A, Richter H, Peters J, et al (2007). Structured J Nerv Ment Dis 195:

15 Individual CBT Models

16 Harvard (MGH) Model

17 Harvard (MGH) Model Module 1: Psychoeducation, Organization, Planning (1-5) Module 2: Reducing distractibility (6-7) Module 3: Adaptive thinking (8-10) Module 4: Additional skills (11-12) 12 session model Individual treatment Safren, Perlman, Sprich, & Otto (2005). Mastering Your Adult ADHD. Oxford.

18 Module 2: Coping with Distractibility Gauging one s attention span: Time it Distractibility delay (Apply chunks from problem solving that coincide with the length of one s attention span for difficult or boring tasks) Modifying the environment

19 Using Reminders & Alarm Device Place colored adhesive dots on items that are often distracting (telephone, computer, window) Set alarm to go off at regularly scheduled intervals (every half hour) Am I doing what I am supposed to be doing or did I get distracted?

20 Keeping Track of Important Objects Ask client to think of difficulties keep track of important objects (keys, wallet, notebook, cell phone) Find specific place in house where these objects will be kept Stress the importance of placing item in its appropriate place immediately Involve other family members

21 U Penn Model

22 U Penn Model Case conceptualization focused approach Approx. 20 sessions over 6 months Getting started (1 + 2) start small, prioritize goals/skills, motivation Early sessions (3 6) education, skill-based HW, formulate Middle sessions (7 15) continue to develop/implement coping skills, comorbidities, cog modification Later sessions (16 20) maintain and generalize skills, relapse prevention Ramsay & Rostain (2008). Cognitive Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach. Routledge.

23 Summary of Interventions Conceptualize patterns WHY don t I change? (EDUCATE) Consider alternatives / gain skills HOW can I change? (EXTEND) Gain novel experiences / face challenges WHEN do I change? (EXECUTE)

24 CBT Model Developmental experiences Difficulties in school, inconsistencies, variable outcomes, ADHD Core belief I am incompetent Intermediate beliefs If I don t understand, I will never get it Compensatory strategies Expects not to learn / heightened distractibility / avoids lectures + studies Activating event Listening to lecture Beliefs This is too hard. I m not college material. Consequences Leave class, low grades, sad/anxious, drops out of school

25 Attitude Adjustments Core Beliefs Failure Mistrust (of self) Inadequacy Defectiveness / Shame Automatic Thoughts Overgeneralization Magical thinking (e.g., meds) Comparative thinking All-or-nothing thinking Shoulds Internalization / Externalization Mind reading / Fortune telling Magnify / Minimize

26 Common thoughts I ve tried before. Nothing works for me. Jim does not have to write down everything (therefore, I should not have to do it.) This is really hard. It s going to be awful. I remember how bad it was when I tried it before. I would not be facing this now, if I had done it before.

27 Cognitive Modification 1. Catch and write down thoughts 2. Compare with the evidence ( defense attorney ) 3. Identify potential flaws in reasoning 4. Develop alternatives 5. Consider worst-case Likelihood? Handle it? 6. Best case.. Likelihood? Handle it? 7. Most likely case? 8. How can I influence this situation? 9. How would I advise a friend? 10. Talk out loud to yourself, talk through the plan

28 Differences in Treating Subtypes: Hyper/Impulsive v. Inattentive Hyperactivity / Impulsivity Impulse control Warning signs, risk factor Harm reduction Coping afterwards Challenge thoughts of no control Reinforce trouble avoided Small tasks, challenges Inattention Information management Know informational pace Repetition, repetition... Get it before you lose it Challenge thoughts of this won t work Reinforce use of skills Diligence, resilience

29 Group CBT Models

30 Mount Sinai Model

31 Mount Sinai Model Intro/goals/methods (1) Time management (2-6) Awareness + scheduling Manageable tasks + rewards Prioritize + to-do lists Emotional obstacles Activation + motivation Getting organized (7-9) Set up system Implement system Maintain system Plan a project (10) Project planning (11) Coping in the future (12) Optional additional session Solanto (2010). Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction. Guilford.

32 Targets of Treatment Problems with time-estimation (late and missed appointments) Procrastination, avoidance (failure to initiate) Failure to follow through, especially on boring, routine, nongratifying tasks (e.g. bills, laundry, mail, taxes) Failure to STOP and shift to a new task as appropriate (failure to inhibit, misnamed hyperfocus ) Difficulties with organization (losing & forgetting) Measured using our ON-TOP questionnaire Failure to plan, short- and long-term

33 Treatment Parameters Group modality (can be adapted for indiv therapy) Exclusive focus on TOP skills 12-sessions, 2 hours, 6-8 persons Components of each session Review of home exercise (1 hour) Presentation of new material In-session exercise Review of upcoming Home exercise Handouts summarize the session, home exercise

34 Rationale for Exclusive Focus on TOP* Skills Inefficiency and/or disorganization virtually universal among adults with ADHD Problems of impulse control/communication are not. Intensive, extensive program necessary to generate real change in TOP* skills Separate intensive program, employing different techniques necessary to address impulse control/social problems *TOP = Time Management, Organization, Planning

35 Cognitive-Behavioral Approach Some components aim to change behavior New skills New habits Other components focus on changing cognitions while imparting skills Adaptive internal speech, self-instruction Use of axioms to promote generaliza/maintenance Cognitive changes generate behavior changes, and vice versa Neuropsychologically informed Name change from Meta-Cognitive therapy

36 U Freiburg Model

37 Conceptual Work Common Features of Adult ADHD and Borderline Personality Disorder: Affective Instability Impulsive Behavior Disorganization Substance Dependence Relationship Problems Attention Deficits (Dissociation in BPD) Low Self-esteem Davids und Caspar, 2005; Philipsen et al. 2006, 2008, 2009; Matthies et al. 2011

38 Dialectical Behavioral Therapy (DBT) based Group Program (Freiburg Program) Symptoms in ADHD Impaired Attention and Concentration Hyperactivity, Disorganization, Stress Intolerance and Impulsivity Affective Lability, Hot Temper Disturbed Interpersonal Relationships Skills Training in DBT Mindfulness Training Stress Management Emotion Regulation Interpersonal Effectiveness Linehan 1997, Hesslinger et al. 2002, Hesslinger, Philipsen, Richter 2003

39 Overarching Goal: Ability to control ADHD rather than to be controlled

40 Topics Main Objective: to control ADHD rather than to be controlled by ADHD Psychoeducation (Neurobiological Model, Neuroplasticity) Mindfulness Chaos and Control (Time Management, Organization) Analysis of Dysfunctional Behavior / Impulse Control Emotion Regulation Depression / Co-occurring Disorders / Medication Stress Management Dependence (Substance / High Risk) ADHD in Relationships / Self-respect Transferral to Self-help Groups

41 Formal Procedure Written Information, Commitment Weekly Group Meetings (Minimum of 13 two-hour Sessions) 6-9 Participants, 2 Therapists Workbook (Hesslinger, Philipsen, Richter 2004), Homework, Written Materials Additional Counseling with Family Members or Partners Additional Individual Direct or Telephone Counseling

42 Structure of DBT-based Group Sessions (Hesslinger, Philipsen, Richter 2004) Short Mindfulness Exercise (2-3 Min) Pressing Topics Review of Skills Chart Homework Mindfulness Exercise (2-3 Min) Introduction of the Following Topic (e.g. Behavioral Analyses) Explanation of Homework for the next Session Wind down Short Written Evaluation Forms

43 Common Themes Across Models

44 Cognitive Interventions Modify distorted cognitions, beliefs Develop valued personal goals Prioritize treatment objectives Planning and organizing Decision-making Problem-solving Attention regulation, capacity building Affect regulation

45 Behavioral Interventions Time management Organization, Environmental engineering Planning / Implementation focus Communication skills, assertiveness Resilience (e.g., using skills) Frequent reinforcement Activation (e.g., 10 minute rule ) Refocusing reminders (i.e., alarm)

46 References Philipsen A, Richter H, Peters J, et al (2007). Structured group psychotherapy in adults with attention deficit hyperactivity disorder: results of an open multicentre study. J Nerv Ment Dis 195: Philipsen A, Graf E, Tebartz van Elst L, et al (2010). Evaluation of the efficacy and effectiveness of a structured disorder tailored psychotherapy in ADHD in adults: study protocol of a randomized controlled multicentre trial. Atten Defic Hyperact Disord 2(4): Ramsay JR, Rostain AL (2008). Cognitive Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach, New York: Routledge, Taylor & Francis Group. Ramsay, J. R., Rostain, A. L. (2012). CBT without medications for adult ADHD: an open pilot study of five patients. J Cognitive Psychotherapy 25: : Rostain AL, Ramsay JR (2006). A combined treatment approach for adults with ADHD: results of an open study of 43 patients. J Atten Disord 10:

47 References Solanto, M. V., Marks, D. J., Mitchell, K. J., et al (2008). Development of a new psychosocial treatment for adult ADHD. J Atten Disorders, 11, Solanto MV, Marks DJ, Wasserstein J, et al (2010) Efficacy of Meta-Cognitive Therapy for Adult ADHD. Am J Psych iatry167(8): Solanto MV (2011). Cognitive Behavior Therapy for Adult ADHD: Targeting Executive Dysfunction. New York: Guilford Press. Safren SA, Otto MW, Sprich S, et al (2005). Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behav Res Ther 43: Safren SA, Perlman CA, Sprich S, Otto MW (2005). Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program Therapist Guide (Treatments That Work). New York: Oxford University Press. Safren SA, Sprich S, Mimiaga MJ, et al (2010). Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA 304: