You started a stimulant medication for a young woman with ADHD. When she returns her symptoms are 70% better, but what can we do about the rest? Today a conversation with psychiatrist Scott Shapiro about behavioral interventions for adult ADHD.
Published On: 09/14/2023
Duration: 13 minutes, 07 seconds
CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. And this is a throwback Thursday episode, where we’re going to update this 2019 classic with new research and CME credits at the end.
On our November, December issue we covered some of the more controversial topics in adult ADHD, such as what really happens when people don't have ADHD but take stimulants to enhance their cognition.
But what about real adult ADHD? Symptoms of ADHD tend to improve as the brain matures into adulthood, but for about one in three, the disorder continues to affect their adult life. Today I'll talk with Dr. Scott Shapiro, a psychiatrist in New York City who specializes in combined psychotherapy and medication for adults with ADHD. Dr. Shapiro, from your perspective, is ADHD a trait that many people have to some degree or is it a disorder that you either have it or you don't?
DR. SHAPIRO: 1st that's a great question. People can have traits of ADHD such as procrastination or struggling with focus or getting up and down at work. But. But that's not necessarily ADHD. ADHD really is a cluster of symptoms both that are in the DSM 5 as well as many symptoms that are not in the DSM 5, such as executive dysfunction and emotional dysregulation. So I definitely myself see it as a disorder as opposed to trait.
CHRIS AIEN: Executive dysfunction? You said that's not in the actual DSM criteria, but I imagine that's got to cause some problems for the patients.
DR. SHAPIRO: Well, it does even more than some of the core symptoms that are discussed in the criteria such as focus and organization and hyperactivity. You know executive function such as planning, strategizing, using behavioral as well as cognitive abilities to really stick to a plan and a project to achieve a vehicle through. And for what I really see has been the challenges with executive dysfunction causing even more impairment than some of the core symptoms of the diagnosis. Problems with people at work procrastinating, attention to detail, really being able to extend the big picture together, but also to attend to granular details. Often along with executive function, emotional dysregulation, being able to regulate some of their own emotions, such as anxiety or anger, or irritability can absolutely impact someone's ability to perform well at work.
CHRIS AIKEN: Our issue went over some of the false positives where ADHD might be wrongly diagnosed, but on the other hand, do you think it's also under diagnosed in adults?
DR. SHAPIRO: About 3 to 5% of the adult population have ADHD that has existed since childhood, and about 85% go undiagnosed and untreated so screen for it in all of your patients.
CHRIS AIKEN: And so many adults have other psychiatric disorders, along with ADHD. How do you manage that?
DR. SHAPIRO: My training was really to evaluate someone for depression or suicidality or bipolar or OCD, and I noticed that that's very rarely, even if ADHD was suspected, that it was never a priority or treated. Some people I've seen have been on antidepressants or mood stabilizers for years, and when their ADHD, often anxiety the depression, the alcohol use often gets a lot better. If someone has ADHD as well as depression and anxiety, my recommendation is to treat ADHD first and not to ignore the other issues. In the one case that I would not treat the ADHD first would be if there was a medical issue such as cardiac or blood pressure situation where they needed to get evaluated first, or if they had something like schizophrenia or bipolar disorder. But even with bipolar disorder before it's treated, or even with hypertension, as long as they've seen the cardiologist, and that's being managed, the ADD must be treated.
CHRIS AIKEN: One thing a lot of clinicians struggle with is the difference between bipolar disorder and ADHD. Certainly hypomania if you read it loosely, can look just like ADHD. You're driven, hyperactive, distracted, racing thoughts, impulsive. How do you distinguish between ADHD and the mood swings of bipolar.
DR. SHAPIRO: There is a lot of overlap. You know, the research shows that people that have ADHD have a much higher chance of having a bipolar disorder, so it's 20%, and then people with bipolar disorder have a higher chance of having ADHD. But in terms of distinguishing if someone has purely ADHD or bipolar; with bipolar you would have symptoms during the hypomanic or manic or mixed state of irritability or impulsivity, or decreased need for sleep or change in behavior. And in ADHD, it doesn't really go up and down like that. First of all, the person may have impulsivity, that's kind of been a lifelong pattern. So you're really looking much more at patterns and what's been happening life long versus, you know, what's coming and going that you see in the situation like bipolar.
CHRIS AIKEN: One thing we always want to do working with patients is to build from their strengths. What are some of the strengths you tend to see in people with ADHD.
DR. SHAPIRO: There are many strengths. You know when I say that this is global, but some things that you would find as strengths within the ADHD population would be passion, high energy, lots of creative ideas and thinking outside of the box. Lots of people with ADHD can also be charismatic and can actually have achieved great success on as an entrepreneur or as a leader, or in in the entertainment industry or in sales.
CHRIS AIKEN: And what's a reasonable goal in medication treatment? Can we expect the ADHD symptoms to go away entirely or is just getting a significant response good enough?
DR. SHAPIRO: In terms of someone that comes to me, that has ADHD it's managing symptoms. You're not looking or able to really achieve permission. And so the complete treatment would be medication and therapy.
CHRIS AIKEN: Starting with what we can do during a brief medication visit, what are the top behavior strategies you have for adult ADHD?
DR. SHAPIRO: When you see someone, either for an appointment, there's always more time than just writing this prescription, and I think we can really do a great service to our patients Behaviorally. Dr. Russell Barkley, medical schools in South Carolina has done a lot of research about the benefits of exercise. We all know about the benefits for depression, but in terms of ADHD, many people have known that exercise helps them feel better and perform better. That improves executive functions, so one of the aspects of the ADHD executive function that's not so addressed very well with stimulus, that it can be improved with exercise, so that would be one thing. Number 2 is helping the person consider the old fashioned week at a glance calendar because often people with ADHD are much more visual. They do find people that use an analog good old fashion, week at a glance calendar, do significantly better and where they plan each day the night before.
DR. AIKEN: That's interesting. I've worked with some cognitive rehabilitation therapists, and they emphasized the same thing in working with patients with memory problems. They recommend a pen and paper visual calendar where the patient can see the big picture.
DR. SHAPIRO: There's a lot of research that's come out that was been lost with the typing and what you get when you go back to the pencil or pen, is that memory and being able to think strategy quickly and granularly on a small level as well as come out and see the big picture its really enhanced with the kinesthetic of handwriting.
DR. AIKEN: Are there any particular calendars you recommend?
DR. SHAPIRO: Whenever I work with someone, it's always very collaborative and so it needs to really kind of resonate with that patient. But the one that I would start off with would be The Week at a Glance where you see the whole week and where you already have the hours of the day scheduled out and not one of the itty bitty ones that you put in a bag and throw away. That's the full 8 1/2 by 11 size count or they can really put not just when meetings are, but some of the actual behaviors you're going to take and to make progress towards your goals.
CHRIS AIKEN: To find that specific calendar, look for the brand, Week at a Glance.
KELLIE NEWSOME: In the past year, several papers have come out confirming Dr. Shapiro’s remarks about exercise and executive function in ADHD. One of that has a particularly wide scope is a 2023 metaanalysis of 59 trials in children and adolescents, and the way it divided up the exercise interventions made me realize just how complex this subject is.
In depression trials, they usually divide exercise into resistance training – like weight lifting – or aerobic – which is anything that gets you breathing faster and speeds your heart rate up. Generally, 45 minutes of aerobic exercise every other day works best for depression.
For ADHD, many of the trials involved went beyond what you’d do at the gym to involve more team sports and complicated skill-building. Here’s how they divided the ADHD studies up
1. Open-skill activities: These require people to react in a dynamically changing, face-paced environment, like soccer, table tennis, and basketball.
2. Closed-skill activities: These require less interaction with others – the person does a repetitive exercise like swimming, running, or skipping rope.
3. Exergaming: These are videogames that require enough motion to count as physical exercise, but also train the brain as well, like Wii Sports
The biggest effect was for the open skill activities that test the mind and body – like team sports or tennis – these had twice the effect size as general exercise. But even general exercise had a large effect size – 1.0 – for executive functioning, so what we’re saying here is that sports have a massive benefit for ADHD.
However, closed skill activities like aerobics and running had a bigger effect for working memory and attention. That is in line with studies in older adults, where aerobic exercise has a large effect size – again around 1.0 – for improving memory.
KELLIE NEWSOME: Earn CME for this podcast through the link in the show notes. Here’s a preview of the quiz:
1. Which intervention improves executive function in ADHD with a large effect size?
A. Vocational rehabilitation
B. Mediterranean diet
C. Schema-focused cognitive behavioral therapy