What is ADHD Coaching?
Joel L. Young, MD and David Giwerc, MCC
Although Attention Deficit Hyperactivity Disorder (AD/HD) is generally considered a disorder of childhood, at least half of the children who have AD/HD will continue to exhibit varying degrees of the disorder after they have become adults. (Weiss, 1993) Some sources claim an even greater prevalence. In fact, the exact number of adults who have AD/HD remains unknown. ADD Coaching
Wender (2000) notes that the negative consequences of AD/HD are greater for adults than for children. Whereas impulsivity in the classroom may result only in a teacher's reprimand, impulsive adult activities have consequences that are more serious. ADHD adults are more likely to have driving accidents, license suspensions, and speeding tickets. Adults with AD/HD can be impulsive shoppers, especially wit h when they are armed with one or more credit cards, initiators of unwise business activities, and participants in short-lived romances and marriages. Wender also notes that spouses of adults who have AD/HD feel "unheard" and unimportant. While the child with AD/HD may feel isolated and alone on the playground, the adult with AD/HD often feels isolated and alone in his or her own home. In fact, adults who have AD/HD face many unique challenges that are a direct result of their disorder, including problems with interpersonal relationships, difficulties getting and keeping a job, and other lifelong impairments. These difficulties become more complicated when the patient is undiagnosed or did not receive appropriate treatment for AD/HD as a child. In many cases, individuals diagnosed with AD/HD during childhood may have discontinued treatment during their teenage or young adult years. The adult who has undiagnosed or untreated AD/HD often does not understand their condition or how it impacts the lives of those who have it and may thus be resistant to traditional treatment.
Better diagnostic techniques and therapeutic interventions have made it easier for physicians to care for patients who have AD/HD. There remain, however, several tasks that the physician must address if he or she is to properly diagnose and treat the adult who has AD/HD. The physician, typically a pediatrician, psychiatrist, or primary care doctor must be comfortable in making the diagnosis. Research clearly indicates psychopharmacology's prominent role as an AD/HD intervention. Therefore, the physician must be proficient in managing any medications used to treat AD/HD and any comorbidities that may be present.
It is important that the physician remember that AD/HD is a pervasive disorder that affects virtually all areas of the patient's life. While most physicians may be comfortable making the diagnosis and prescribing a course of treatment, the primary care physician may not feel as well versed in qualified to tend ing to the critical behavioral issues that accompany AD/HD. Even if the primary care physician is comfortable with treating the adult with AD/HD, the typical office visit does not allow sufficient time to address in great detail every issue that typically confronts the newly diagnosed AD/HD patient. Thus, while the patient may leave the office with an appropriate medication regimen, many other critical problems related to the diagnosis may remain unaddressed.
Medications can improve focus and reduce other symptoms of AD/HD. However, medications alone cannot teach the patient how to compensate for life skills that were never learned. For example, people acquire social skills and good manners during childhood. Socially appropriate behaviors are expected to be well established by the time the patient enters adolescence or young adulthood. Unfortunately, the child who has AD/HD often does not learn age-appropriate social behaviors. The gap between expectations and performance continues to widen as the child grows up. Socially inappropriate children grow to become socially inappropriate adults, often with tragic consequences. Thus, while medication may make the adult with AD/HD more attentive and less impulsive, medication cannot teach the adult how to carry on a conversation or to behave in a socially acceptable manner.
In many ways, the scenario of the newly diagnosed AD/HD patient is analogous to the example of a young child who has not yet learned to walk yet somehow manages to break his leg. A physician would treat the patient and place the broken leg in a cast. In due time, the leg would heal and the cast would be removed. However, the child must continue to crawl because the injury had occurred before he had learned to walk. The same is true of patients who have AD/HD. Medication may correct problems of inattention, hyperactivity and impulsivity and make the patient capable of having a relatively "normal" life. Yet, the patient with AD/HD is somehow expected to function as a normal adult with little or no training in adult living. This puts even the medicated adult with AD/HD at a great disadvantage. Although the patient may be capable of more appropriate behavior, he or she must still learn what is expected and how those expectations might be met.
Traditional psychotherapy may not be appropriate for patients who have AD/HD
To help address these behavioral components of AD/HD, the physician has historically relied upon other mental health professionals such as psychiatrists, psychologists, or clinical social workers. The combined efforts of the clinician and psychotherapist allow greater patient access to the clinician for medical management. Such a team approach can provide the AD/HD patient with appropriate support with those therapeutic issues that frequently accompany the condition. Surveys of physicians indicate that general practitioners view their role in the care and treatment of patients who have ADHD care as largely supportive in nature and involves close liaison with specialist services. (Shaw, Mitchell, Wagner, & Eastwood, 2002)
Unfortunately, other important issues such as cognitive restructuring needs, time and stress management, self-esteem, and relationship difficulties are often not within the domain of the psychotherapist, who is usually more concerned with resolving whatever underlying causes may be affecting the patient. AD/HD is not depression (although depression is a common comorbidity among those who have AD/HD). Current thinking about AD/HD indicates that it is a brain-based, biological disorder. It is not believed to be the result of childhood trauma, post-traumatic stress disorder, or other conditions for which psychotherapy traditionally has been indicated. Again, these conditions can and often do exist alongside AD/HD. They are, however, separate and apart from the AD/HD diagnosis.
Psychotherapy can help the patient who has AD/HD as they seek to understand and live with their condition. However, psychotherapy alone is typically not enough. The patient who has AD/HD also needs practical strategies that will allow him or her to accomplish even mundane daily tasks like getting to work on time, making regular payments on their bills and learning other basic life skills. Furthermore, the AD/HD adult is often trapped in a frustrating cycle of failure that severely limits the patient's quality of life. One of the hallmarks of AD/HD is the gap between ability and performance. This gap must be closed or reduced if the patient is to enjoy the full benefits of treatment.
The psychotherapist who does not understand AD/HD and inappropriately pursues traditional or psychoanalytic modalities presents a frequent obstacle to appropriate care. The patient often feels frustrated and may discontinue treatment altogether if he or she cannot see more immediate and appropriate results.
The AD/HD Coach (the ADD Coach)
Coaches use highly pragmatic approaches to problem solving. The main objective of coaching is to identify what is preventing the client from reaching a specific goal and to work with the client to create a specific plan for reaching that goal. Coaching is becoming increasingly popular among high-performance individuals who may or may not wish to use a therapist and in fact may not require psychotherapy but could benefit from having someone help them with motivation, organization and with other life skills. Coaches are not restricted to helping people with AD/HD and have been used by people from all walks of life.
Therapy and coaching are not the same. The two disciplines are not interchangeable. In fact, some AD/HD clients see both a coach and a therapist at the same time as part of their personal AD/HD management program. Coaching completes the bridge between biology and behavior and narrows the gap between ability and performance and performance. Many patients and physicians are beginning to realize the importance of including an AD/HD Coach as a part of the treatment team. Just as an athletic coach motivates an athlete, AD/HD coaches are also very adept at motivating their clients who have AD/HD.
Many adult AD/HD clients have often stated that it was a coach who was the first person to not only understand the frustration of their challenges but they were the first person to sincerely believe all of their AD/HD stories.
The less formal coach/client connection is more conducive to personal encouragement and motivation than the traditional doctor/patient relationship. Physicians can rarely provide this level of attention and encouragement within the restrictions of the typical office visit. The coach becomes the client's champion, reinforcing and reminding them of their natural talents and successes. The skilled AD/HD coach creates a safe environment that encourages the honest and open communication necessary if behavioral changes are to occur. This environment exists on a foundation of unconditional acceptance of the client coupled with science-based instruction about AD/HD. Within such as structure of safety, the coach focuses on identifying and acknowledging the natural talents of the individual and eventually on developing a plan to convert them into daily strengths.
Many AD/HD coaches also have AD/HD and are therefore intimately familiar with the challenges faced by those who have the disorder. Although having AD/HD is not a requirement for being an AD/HD coach, the coaches who have been diagnosed offer to their clients a heightened sense of empathy and hope that they, too, can master the particular challenges concomitant with the condition.
AD/HD coaches help the patient develop problem solving skills and strategies to cope with AD/HD. This can be a valuable adjunct to medication management. The ADHD coach is a specialized professional who provides psycho-education support, cognitive behavioral awareness, pragmatic results oriented techniques and strategies, which augment the benefits of medication. In some cases, coaching may be used as a first-line treatment for those patients who are reluctant to use psychotropic medications or therapy. While coaching cannot replace stimulant medication as a treatment for AD/HD, a coach can provide some strategies for accommodating the disorder. In addition, the coach can provide education about AD/HD that may encourage the patient to pursue medical treatment. Depending on the specific needs of the patient, the AD/HD coach may also address the benefits of specific life-style issues such as proper sleep, nutritional habits, and exercise. In addition, AD/HD coaching is highly accessible to the client without need of geographical proximity or travel. The ADHD coach contributes significantly to the optimal treatment of the ADHD patient.
Keeping the client focused
AD/HD patients characteristically have a great deal of difficulty maintaining their focus. Medication can help, but even with medication, the adult who has AD/HD may still experience times when focus is minimal at best. The coach helps determine how the client attends to different challenging tasks by identifying distinct phases of attending:
• Focusing on the intended stimulus
• Sustaining focus
• Shifting focus at will
• Hyper-focusing (intense focusing on negative thoughts that can lead to rumination)
• Hypo-focusing Hypo focusing or daydreaming. This is the weakest level of focus and pre s vents the greatest challenge.
• Cognitive hyper activity: A preponderance of thoughts that bombard the individual at high velocity.
Once the various phases of focus have been identified and understood, the coach works with the client to develop strategies that will help maintain focus.
Psychoeducation is an integral part of the coaching process. It is during this phase of the coaching relationship that the coach educates the client about how and where the challenges of AD/HD are manifested in their life. The knowledgeable AD/HD coach understands and has the ability to explain the bio-neurological nature of AD/HD sufficiently in ways that capture the attention of their client. For example, people who have AD/HD tend to be visual thinkers, and AD/HD coaches are taught to use creative metaphors to help the patient visualize how AD/HD affects their life and how it might be overcome (the prefrontal cortex as the steering wheel of the car, for example) and meaningful distinctions (for example, "can't" vs. "won't"'; perfection vs. excellence; interrupt vs. clarify). A better understanding of AD/HD comes through the use of simple, stimulating language and unique models (see sidebar, "The Machine, The Mind and The Mission" as an example). These techniques help the client become an active participant in their own education, seeking answers to important questions about their own individual "brand" of AD/HD.
During the psychoeducation phase of coaching, the AD/HD coach shares information supported by scientific research about AD/HD. The credibility of this documented and proven body of knowledge from reputable and respected sources, such as health care institutions, organizations and other authorities on AD/HD illustrates and explains the client's past inability to perform as a function of undiagnosed and untreated AD/HD, not as a result of being "broken" or having had a character flaw. Understanding how AD/HD affects the brain and the life of an individual diminishes, and in many cases, eliminates years of self-blaming behaviors that have contributed to the low self-esteem of the individual who has AD/HD and the continued cycle of failure.
The patient with AD/HD is sometimes tempted or even encouraged by well-meaning well meaning but uninformed clinicians to use their disorder as a justification for inappropriate behaviors. Such excuse making is not healthy and impedes the progress of the patient. The skilled AD/HD coach teaches the patient that AD/HD is a brain-based disorder, with unique strengths , while at the same time emphasizing that AD/HD is not an excuse for past mistakes or other problems . . - The message is that "It is not your fault, but it is your problem." The coach must teach the client the distinction between having an excuse and having an explanation for their behavior if the client is to have a greater understanding and awareness of their challenges and to move forward.
Despite the fact that there are only a few well-established comprehensive coach-training programs, coaching is fast becoming a popular intervention. Not enough well trained coaches have the necessary understanding of AD/HD, its challenges and the coaching skills required to effectively coach the large number of adult AD/HD individuals who are requesting coaching services. Therefore, clients should request that potential coaches provide references from previous clients, ask prospective coaches about their training and certification, and inquire about their knowledge of AD/HD.
The AD/HD coach is a valuable part of the comprehensive, multi-modal treatment for AD/HD. Coaches have the knowledge and ability to provide strategies for success that the physician and therapist may not be able to adequately address.