Could a Strength- Based Treatment Improve Self-management in Adults With Attention Deficit Hyperactivity Disorder

ADHD symptoms negatively affect daily functioning both at work and at home, and have long-term impact in academic, occupational, social and emotional areas of functioning. Effective, long-term treatment outcomes benefit both the individual with ADHD and society as undiagnosed and untreated adults with ADHD may become an economic burden due to increased health care costs and decreased productivity at work. Russell Barkley postulated the first unifying theory of ADHD which places a core deficit of behavioural inhibition at the source of ADHD behaviours. Barkley's model is built upon observation of perceived chronic difficulties in behaviour, measured as "excessive or inappropriate for their age or development level.". Since the publication of this model, several theoretical models were proposed which attribute alternative cognitive sources for the development of ADHD symptoms, but Barkley's model forms the foundation for primary treatment recommendations. A recent review of the theories of ADHD recommended that more testable hypotheses need to be produced. While a variety of different interventions are available and the benefit of other forms of support is acknowledged (e.g. psychotherapy or coaching), the National Institute for Health and Care Excellence (NICE) only recommends interventions that match a similar protocol to medications: Randomised Controlled Trials (RCTs), which are primarily based in Cognitive Behavioural Therapy (CBT). It is therefore hypothesised that much of current research for the characterisation of ADHD is based on a cognitive behavioural paradigm that is deficit-focused with primary treatment outcomes of symptom reduction and control of maladaptive behaviours. Research in psychology suggests that a deficit-focus may not be the best approach to improving mental health, and it may be necessary to develop positive psychological factors and emotions that cultivate health and wellbeing. In ADHD, research suggests that this includes cognitive dynamism, creativity, and resilience, among others. There is a paucity of research in this area.

This project proposes an alternative approach to understanding and working with ADHD behaviours, supported by Self Determination Theory (SDT). SDT is an empirical, organismic dialectical approach to human motivation and personality, originating in Positive Psychology. SDT guided research focuses on conditions that enhance intrinsic motivation, self-regulation, and wellbeing. The positive approach to active energisation and intention of behaviour in SDT is closely aligned to evidence of positive engagement in ADHD (e.g. via interest), therefore viewing ADHD behaviours from an SDT perspective allows for a different understanding of the action and intention of behaviour. An SDT based approach combined with psychotherapeutic principles for integration of a positive concept of self provides tools which are potentially effective for long term treatment.

One of the challenges to designing effective treatment is the variability of impairment experienced by individuals with ADHD. Impairments are viewed as "clusters" of chronic difficulty for everyone with an ADHD diagnosis, however individual profiles can differ significantly. This implies there are situations or contexts where individuals with ADHD can function successfully. Two phases of this project have been developed to support this hypothesis. The aim of Phase 2 is to generate a theory, grounded in data, that explains a) why and how individuals with ADHD experience variable impairment; b) the impact of variable impairment for those with ADHD; and c) processes and strategies used by those with ADHD to resolve their main concerns regarding the impact and consequences of the variable impairment of ADHD. The purpose is to identify universal selective strengths that support individuals with ADHD to manage the variability of their impairment. In support of these alternative theories and approaches, Phase 3 of this project aims to examine the participant acceptability, feasibility, and efficacy of a novel strength - based programme of therapeutic self-development, psychoeducation and skills training for adults with a diagnosis of ADHD. This programme will use a multi-modal psychotherapeutic approach and educational methodology to assist participants in understanding ADHD and develop self-management skills.

While ADHD is primarily viewed as a neurobiological disorder with no cure, the possibility that ADHD may confer advantages to the individual is widely debated. Research on phenomena concerning the experience of ADHD has theoretical implications, and grounded theory is presented as a research methodology that is ideal for an area where not much research or theorising has been done before. There are currently several methodological approaches to grounded theory, and for this project it was deemed most appropriate to use a Constructivist approach. This approach introduces a pragmatic epistemological perspective on the researcher by recognising the subjectivity and researcher involvement in construction and interpretation of data in theory construction. This was thought to be an important element to monitor during the research process due to the researcher's own personal experience of ADHD.

In keeping with the focus on selecting cases which may provide new insights for developing theory, this project will aim to approach three different groups for participation: NHS patients from the Adult ADHD Clinic at the Southwest Yorkshire Partnership NHS Foundation Trust; university students at the University of Huddersfield and the University of Cambridge; and ADHD Support Groups for adults with ADHD. Analysis of individual case studies was considered, however as current perspectives of positive psychological factors in ADHD are identified as "individual strengths", it was thought a case comparison on interviews might identify the phenomenon in a more universal way.