Conclusion: How I Treat Adult ADHD With Dr Napoleon Higgins

Watch Dr Napoleon B. Higgins, Jr. discuss how he treated Jenice, a 55 year old patient with comorbid anxiety, depression, and ADHD who was successful at work but experiencing trouble maintaining her home life.

Note: The patient's name and identifiers have been changed for anonymity. 

Read the transcript:

Hello, my name is Dr Napoleon Higgins. I am a child, adolescent, and adult psychiatrist in the Houston area. I'm also executive director of the Black Psychiatrists of America and CEO of Global Health Psychiatry. I treat ADHD and all mental health disorders. I see persons of all ages—I love what I do and I love to help our patients get better.

My case today is a story about Jenice. Jenice is a 55-year-old Black female who is an uber professional as an accountant, a profession she’s been doing for many years. She's done a very good job at the work that she does. She fully engrosses herself in her work, but the issue has become that despite her doing well on the job, there are things that she notices that are a problem at home. So far, her issues have been not being accountable or often missing things inside of the home such as being there for the family, being there for the children, being there for her husband, and forgetting dates and times. The issue has been that she could focus in on her job at work, but then having difficulty focusing at home.

On the other side of the issues at work, even though she engrosses herself as a manager, she also still does notice that there are problems with being timely about the work that she does or the issue of being disorganized in the work that she puts forward. She can, at times, very well focus in on the job, but some of the mundane tasks that she's not as interested in, she seems to start to struggle with as well.

The issues that primarily brought her in were issues of her marriage where (1) her husband felt like she was not paying attention to the issues that were needed with her and the children, (2) the issues of paying some of the bills on time, especially with her being the primary wage earner, or (3) there are things that they needed or decisions that needed to be made that she seemed to try to avoid.

Her husband was unable to count on her to help out with the children and their homework and making sure the children had things completed on time, getting to practice on time, making sure that they had all their materials together.

Despite being at work and looking as uber professional, very well regarded in the type of the work that she did, the issue became damage to the marriage and not being able to meet expectations inside of the home and the other spaces that were going on inside the family. 

She was referred to by a family therapist actually for anxiety because she would have a lot of issues when it came to talking to her husband and him asking questions and feeling like she needed to be able to come up with an answer. But really her problem was she would just forget.

They would come up with a plan, things that were supposed to be getting done for the family and her not following through. He felt like she was aloof or really didn't care about the home. So , as I was evaluating that, I noticed that it all seemed to keep following back to "I forgot this, or I'm trying to cover ground, or I'm trying to make up for what I was thinking at the particular time."

From there it became the issue of treatment. What do we do next? After the evaluation where we looked at anxiety, we started paying attention to the issue of depression, and now she's becoming upset that she's not meeting the expectations as well and feeling like she's a failure despite the world believing that she's doing extremely well and that she has everything.

She has a beautiful family; her husband is a professional, she has beautiful kids, but she's struggling to keep up with everything as the kids are getting older and they're having more responsibilities. 

At the idea of "have you ever considered that you may have ADHD?" She took a pause and said, "Well, how could I have ADHD when I do so well at my job? I'm very well known for the work that I do."

I replied, "Do you notice that it seems like you seem to have to cover for something that went wrong or something that was expected that did not get done?"
She said, "I noticed that a lot of the arguments are over those particular things, that I forgot something and that I wasn't paying attention to what was going on, and that I'm really focused at work."

One thing that we fail to realize many times is that when people have ADHD, many times they actually hyperfocus on the things they actually enjoy. When it comes to a particular task, they may be great at that particular task, but other parts of their lives may not be actually being taken care of.

What was very interesting during the pandemic—where we met over video calls—I actually saw her office. She had the corner office with windows on each side, but there were stacks of papers standing at least a foot and a half high all throughout the office. It looked like complete disarray. I asked her, "What is all of this stuff?"

She said, "Well, these are things that I'm working on."

And I then said, "How can you work in such disarray when nothing is actually any place?"

"It's all just kind of laid out where I can see it there when I need to see it. Well, what happens is that I'm disorganized and I can't remember to do anything until I have to trip back over it to remind myself that I need to get it done," she replied.

She’s found herself to be very good at putting out fires around her all the time. That's what she's known for on the job, is putting out a lot of different fires. The problem has become specifically more so at home when she's not able to do that same thing at home or the problem is that you're working and living with another adult who doesn't want the fire, nor are they looking forward to a fire being put out when they were trying to avoid those. But, fires keep fuming up inside the home.

When you look at treatment for this particular individual, for this uber professional woman, what do we do? How do we help her? And where do you start with treatment?

Well, we definitely want to continue the marital therapy. That is what brought the individual in. That's what brought her in to seek actual help regarding the anxiety inside the home and having difficulty speaking to her husband and that, but also with that as I'm always trying to have to cover what I missed and what my thinking was and why these things did not occur.

And so, what we decided to do was actually go to look at the anxiety and we decided to treat the anxiety episodically, but really what we wanted to focus on was making sure that we treated the ADHD.  Because there was anxiety and there was some slight depression, we treated that portion, but we went ahead and started an ADHD medication to help her. She noticed that she had a lot of improvement when it came to the ADHD.  She also noticed improvement with the anxiety and that she wasn't as worried about missing things, as missing deadlines. She was better to be able to be accountable for the other things outside of her job and her work.

She also observed that the tasks at work, and even the stacks of paper, started to diminish, and she actually got a promotion within about a year or 2 within starting the medication. She got promoted to even a higher position within the job as a senior executive, because she was more organized and also because things were able to be taken care of at the house. She was more relaxed on the job, and actually could focus more on the job because other aspects in her life were able to be pulled together.

The multiple options are (1) we could start an SSRI. She came in for anxiety. She's worried about a lot of different things, and it seemed to be non discrete of one particular thing. The biggest issue was the marriage, but there's a lot of issues going on inside the home. So 1, do we start an SSRI, which would be your mainstay treatment for an anxiety disorder and maybe some slight depression because of not meeting expectations that she would like inside of her family and home?

(2) The second would be to refer to continue with the family therapy in that you're in marital therapy right now, continue to work through that, working through the issues. Maybe the expectations are just too high for being an uber professional. The pressures of being a woman, trying to take care of a family, looking good every day, trying to have it all, and maybe the world is asking for too much and we need to continue in marital therapy, maybe even add individual therapy.

(3) The third thing would be putting parameters about what she's available for in the home and that we are career minded, we're career, goal minded, and that he needs to pick up more of the slack inside the home.

(4) A fourth one would be the issue of trying to treat the anxiety, specifically of starting a medication, a short acting medication for anxiety just from when you get home to carry on throughout the rest of the day because this is causing a lot of distress.

(5) And then the last would be starting a stimulant, starting a medication for ADHD as well as addressing the issues inside the home and expectations, and even maybe even starting a medication to treat the anxiety specifically.

The answer to that is I would pick the last one. That is what I chose to do. There's a lot of anxiety inside the home and a lot of stress inside the home.

I gave her a short-acting medication that could help with the anxiety specifically for dealing with the issue and addressing issues inside the home. I did recommend that she do individual therapy as well as marital therapy to understand the expectations. Sometimes you are trying to do too much and looking at how can we shift responsibilities around inside the home, but also the point of starting a stimulant medication for this uber professional who looks to have everything but the fact is that so many things are going on and so many things are being dropped, not being accountable for the responsibilities of the home.

Actually, we found that she was actually having some issues actually on the job as well, even though she had figured out her niche of work but trying to have a person to work at their optimal to their abilities. This patient is a very responsible, hardworking, highly trained individual who ended up getting a promotion once they could pull a few more things together.