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Health and Wellness Coaching and Psychiatric Care Collaboration in a Multimodal Intervention for Attention-Deficit/Hyperactivity Disorder: A Case Report



 

Elizabeth Ahmann, ScD, RN, PCC, NBC-HWC1; Katherine Smith, MPH, ACC, NBC-HWC1;
Laurie Ellington, MA, LPC, RCC, PCC, HMCT1; Rebecca O Pille, PhD, MS, CHWC, CWP1

Perm J 2020;24:18.256 [Full Citation]

https://doi.org/10.7812/TPP/18.256
E-pub: 10/23/2019

ABSTRACT

Introduction: Stimulant medications are the most common treatment for attention-deficit/hyperactivity disorder (ADHD). However, a multimodal approach that includes behavioral interventions may yield better outcomes. Coaching is gaining recognition as a client-centered behavioral intervention for the management of ADHD.
Objective: To examine the collaboration between ADHD-focused health and wellness coaching and psychiatric care to support a client’s improved self-management of ADHD.
Methods: Using the internationally developed CARE (CAse REport) guidelines designed to improve transparency and accuracy in health research reporting, this case report is based on a systematic review of data collected from the point of care.
Results: An 8-week collaboration between a psychiatrist and a health and wellness coach both expanded what the psychiatrist had been able to achieve alone in working with a client with ADHD and resulted in client improvement in self-efficacy and various functional impairments, including organizational skills and academic achievement. The client achieved her goal of resuming graduate studies and both integrated and maintained her behavioral changes for more than 6 months, successfully graduating from her program.
Discussion: This is the first case report, to our knowledge, describing the process of coaching for ADHD and exploring its integration with psychiatric care. It illustrates beneficial outcomes and the promising role of health and wellness coaching in assisting individuals with ADHD in achieving successful behavior change. The client in this case report made progress that was sustained beyond the 6-month mark, an important milestone in the trajectory of behavior change.
Conclusion: This case report suggests that health and wellness coaching can be effective in supporting beneficial outcomes and can be useful in the multimodal management of ADHD.

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD), previously considered a childhood disorder, is now recognized as continuing into adulthood, affecting approximately 4.4% of adults in the US.1 ADHD is characterized by core symptoms related to inattention, hyperactivity, and/or impulsivity2 and is increasingly understood as a disorder of the executive functions (EFs), a set of mental skills comprising the “management system” of the brain, including organization, time-management, planning, initiation, and others.3 Adult ADHD is commonly comorbid with mood, anxiety, and substance abuse disorders and is associated with disabilities in basic and instrumental functioning.1 It affects interpersonal relationships, health and safety, educational and occupational attainment,4 and has a substantial economic impact.5 

The most common treatment for ADHD is stimulant medication, but behavioral interventions appear key for achieving benefits in functional areas such as organizational skills and academic/employment success.6,7 Thus, a multimodal or integrated approach may be ideal to address ADHD impairments and promote optimal outcomes.8 One useful behavioral component of multimodal intervention for ADHD is coaching.9-11 Among the advantages of coaching as a behavioral intervention is its emphasis on client accountability.12 

A recent literature review identified 19 studies that consistently found beneficial outcomes of coaching for ADHD13; however, the studies do not specifically explore the issue of coach collaboration with a psychiatrist or other health care professional in a multimodal or integrated approach. This report examines the use of ADHD-focused health and wellness coaching (HWC) as a collaborative, client-centered intervention offered in conjunction with psychiatric care to assist a young woman in managing the effect of ADHD and related EF challenges on personal health and wellness goals related to academic success. To our knowledge, this is the first case report that explicitly addresses collaboration between a health and wellness coach and a psychiatrist in the management of ADHD. In addition to illustrating the value of coach-psychiatrist collaboration in care of this client, the case report explains the coaching process and indicates positive outcomes that occurred as a result of the coaching intervention focused on improving management of ADHD and EF symptoms and enhancing self-efficacy.

METHODS

This case report provides a systematic review of data collected from the point of care by an ADHD-focused health and wellness coach (EA). The review is based on methods described by the internationally developed CARE (CAse REport) guidelines,14 designed to improve transparency and accuracy in health research reporting. The report summarizes data collected at the point of care, and triangulated when possible, via the client’s self-report, participant observation by the coach, verbal reports of observations by the psychiatrist, and observation of physical artifacts (eg, the client’s written schedule, emails, and both study notes and notebook). The client’s perspective was always considered central to the reporting and interpretation of data. Institutional review board approval was not required for this case report. However, informed consent was obtained from the client to present this article and her perspective, which is included below.

CASE PRESENTATION

Presenting Concerns

A 30-year-old white woman had been dismissed temporarily from a graduate-level physician’s assistant program because of a lack of success academically and in clinical rotations. She was given 8 weeks to establish improved ADHD management for the school to consider allowing her to resume the program. Her psychiatrist recommended coaching, and the client was referred to an experienced coach by the disability services office at the university she attended. Her desire was to establish improved management of ADHD and EF symptoms so she could resume her educational program.

Client History

The client was diagnosed initially with inattentive-type ADHD in 2014 but received no treatment until completing additional testing in 2015. When she presented for coaching, in 2017, she had a psychiatrist who was treating her with dextroamphetamine-amphetamine, which she took regularly. Although her psychiatrist provided some counseling, the client had never worked with a psychotherapist. She periodically used running and yoga to manage her ADHD symptoms, with limited success. Despite previous work as an emergency medical technician, the client reported that she found her current academic program very stressful. Although she had been working with her psychiatrist for some time, the psychiatrist expressed interest in collaborating with a health and wellness coach to help the client better manage her ADHD symptoms with the goal of resuming school.

INTERVENTION

Health and Wellness Coaching Model

The client had 8 weeks before her academic program would reconsider her participation, so she contracted for an 8-week period of HWC—a science-based, client-centered, self-discovery process based on behavior change theory, often provided by trained professionals with diverse health and allied health backgrounds.12 The premise of HWC is that behavior change can be promoted and sustained by linking changes to personal values and a sense of meaning and purpose.15 In HWC, a contractual partnership is established between client and coach, focused on the client’s self-determined goals. The assumption in HWC is that the client is the expert and the coach’s expertise is in the process of helping the client move toward desired health and wellness goals in order to create, over time, lasting behavior change.15 

The coach in this case report was trained in HWC, life coaching, and coaching specifically for ADHD and had been working for 8 years with individuals having ADHD. She held a credential as a Professional Certified Coach from the International Coach Federation and was subsequently credentialed, in the first credentialing round, as a National Board Certified Health & Wellness Coach through the National Board (formerly International Consortium) for Health & Wellness Coaching. Her approach to coaching individuals with ADHD derives from 2 key theoretical frameworks: 1) understanding ADHD as largely a disorder of EFs, and 2) appreciating self-determination theory as key in developing individual motivation and supporting action toward behavior change. She holds her clients in unconditional positive regard while letting the client’s own agenda focus the coaching goals, and without having particular or set expectations of what success should look like for the client or what needs to result from the coaching process.

Health and Wellness Coaching Sessions

Session 1: Initial Health and Wellness Coaching Session (2 hours)

Although the client was distraught about her academic situation, she had a high degree of intrinsic motivation, making her a good candidate for successful use of HWC. The client had previously had little education about ADHD and how it might be affecting her. In HWC, a coach may offer pertinent educational resources to a client12,16; in this case, the coach used Thomas Brown’s3 model of impaired EFs in ADHD to explain and normalize the client’s experience. In addition, the client and the coach jointly reviewed the client’s completed self-assessments (Table 1). These tools were used to increase the client’s awareness of how ADHD affected her life and to help her identify potential coaching goals. Purposeful conversation—supported by open-ended powerful questions and active and reflective listening by the coach (see Table 2 for description of these and other coaching skills used in work with the client)—was used to identify the client’s overarching goals for the 8-week engagement, strengths that might support change, potential obstacles to change, and best ways of working together.

The client and coach also evaluated the client’s readiness to change through conversation based on the Transtheoretical Model,17 an evidence-supported theory that posits that behavior change progresses through a series of stages: Precontemplation, contemplation, preparation, action, and maintenance. An individual’s stage of change for each desired new behavior can suggest how quickly change might take place and can inform the types of coaching interventions helpful in promoting stage-related change.17 The client was in the preparation and/or action phases of readiness to change—defined by an intention to plan for (preparation) or take steps toward (action) behavior change in the immediate future—in regard to each of her identified coaching goals.

The client’s initial overarching goal in HWC was learning to manage her ADHD and EF challenges skillfully enough to resume her graduate program. Goal-related action steps focused on establishing daily routines to support adequate sleep and on-time arrival at her morning clinical rotations; improving her social awkwardness in clinic settings, including improving presenting of patients; improving the organization of her study materials; and improving her study methods. HWC action steps are typically put into a SMART (specific, measurable, actionable, realistic, and time-bound) goal format to promote success.15,16 Both overarching goals and weekly goals are often formulated this way (see Sidebar: Sample Weekly SMART Goals for 2 examples of the client’s weekly SMART goals). Follow-up of each action step occurs in the subsequent HWC session or by text or email between sessions if the client encounters barriers or wants more frequent accountability check-ins with the coach.

Sessions 2-7: Weekly Health and Wellness Coaching Sessions (1 Hour Each)

In HWC, the client determines the focus for each session, and the coach provides both structure and support. In this case, the structure of sessions included identifying the session focus; reviewing the previous week’s action steps (goals), including reflection on learning, identifying any challenges, and celebrating successes; exploring the identified session topic by identifying assumptions, opportunities, strategies, barriers and resources, and engaging in problem-solving as needed; and planning new actions for the following week. In the weekly HWC sessions, the coach used a variety of established coaching skills (Table 2) to promote behavior change that could assist the client in achieving her desired goals.

As is common in HWC, instruction in mindfulness practices was offered as a tool to promote improved self-regulation and stress management. In this case, the coach also encouraged the client to discuss her reports of possible anxiety symptoms with her psychiatrist. For support and accountability, the client and the coach communicated via email and text message between sessions about any challenges faced in implementing the chosen action steps.

Session 8: Final Health and Wellness Coaching Session (1 hour)

The final HWC session provided an opportunity for the client and the coach to identify, reflect on, and celebrate the client’s accomplishments (outcomes) achieved during the 8 weeks of coaching (see Table 3 and Sidebar: Client Perspective). The client and coach also discussed what might help in both maintaining and building on progress made to date.

Interprofessional Collaboration

With the client’s permission, her coach and psychiatrist spoke several times during the 8 weeks of coaching, providing each with a broader understanding of her needs, choices, challenges, and goals, thus optimizing support for the client. For example, the psychiatrist was able to provide the coach with a clinical perspective on the client’s ADHD, the reasons for the chosen medication(s) and doses, and how they affected her functioning. The psychiatrist, who had worked with the client for a number of months before the onset of coaching, also emphasized concerns she thought were essential to address behaviorally (eg, sleep) to support overall ADHD management. The coach shared with the psychiatrist details of the client’s coaching plan and progress, giving the psychiatrist a closer view of the client’s challenges and successes. The coach also shared observations, based on weekly coaching sessions and more frequent communication with the client, about possible anxiety symptoms. This enabled the psychiatrist to modify the client’s medication regimen to more effectively treat her. The psychiatrist also asked the coach to provide a letter detailing the client’s functional improvements (coaching outcomes), which she shared with the client and then forwarded to the university committee considering whether the client could resume her program.

18.256

OUTCOMES

Initial Outcomes

Eight weeks of HWC resulted in multiple meaningful outcomes and improvements for the client in ADHD self-management, EF skills, and self-efficacy (Table 3). Perhaps the most significant outcome of the collaboration was that these improvements, outlined in a letter the psychiatrist forwarded to her university program, allowed the client to resume her academic program.

Follow-up Outcomes

The client was given an opportunity to continue with HWC after resuming school to support maintenance of behavioral changes and address any challenges her new schedule might engender. Because she had achieved her primary goal, as well as for financial reasons, she chose not to continue. However, the coach sent several supportive emails during the first few weeks after the client resumed school, and they spoke by phone after the second week.

In addition, after resuming school and completing a clinical rotation, the client contacted the coach to debrief. The client was pleased to report that she had been on time to her clinical rotation every day, except one (a major improvement in the EF skills of organization and time management demonstrated in the maintenance phase of behavior change); had learned a lot (indicative of improved self-regulation and study skills); was able to accept feedback nondefensively (indicative of improved self-efficacy); and had completed the rotation successfully (involving the use of a number of EF skills gained through the coaching). She had obtained adequate sleep each night (because of improved organization and time management skills); passed her academic tests (likely in part because of better sleep and improved management of her notes and her time); and had begun to feel confident and positive about participation in her academic program (a demonstration of continuous improvement in self-efficacy during the maintenance phase, an ideal outcome of coaching).

After an additional clinical rotation, the client met with the coach for a second follow-up. Although she was not going to sleep as early as she would have wished, she was still getting adequate sleep, had been on time to her clinical rotation each morning, and had again experienced a successful rotation. Although the client had not yet completed school at this point, she invited the coach to her long white coat ceremony, saying “I couldn’t have done it without you!” This statement summarized the value of coaching for this client. Figure 1 shows a timeline of the case.

DISCUSSION

Three key issues are illustrated in this case report: 1) the value of coach-psychiatrist collaboration in successful management of ADHD with a client, 2) the processes involved in coaching, and 3) successful outcomes achieved through a coaching intervention focused on addressing challenges in managing ADHD and EF concerns.

Coach-Psychiatrist Collaboration

Some individuals may choose coaching rather than medical and/or mental health care to address management of their ADHD.18 Although one previously published case study19 describes coaching for an individual with ADHD taking medication and undergoing therapy, this is the first case report, to our knowledge, to explicitly explore the integration of HWC with psychiatric care.

Collaboration between the psychiatrist and coach in support of the client improved the overall care she received and, thus, better supported her ability to attain her desired goals. The outcomes achieved by integrating HWC with psychiatric care included improvements in the following domains: Personal growth and self-efficacy, the ability to “find [her] own resources” (see Sidebar: Client Perspective), daily functioning, organizational skills, interpersonal skills, and self-care (see Table 3 and Sidebar: Client Perspective). In addition, the involvement of HWC in the client’s care facilitated refinement in the psychopharmacologic care provided by the psychiatrist.

In terms of generalizability of the findings in the case report, successful application of the emerging practice of HWC in a multimodal approach for managing ADHD necessitates that psychiatrists are aware of its potential benefits and open to collaboration with appropriately trained and experienced coaches. Clients must be open to engaging in the coaching process as well.

Coaching Processes

General HWC processes have been previously described,12,15,16 and processes specific to coaching individuals, including students, with ADHD have also been outlined elsewhere.19-22 This case report illustrates a blend of these frameworks to show the process, including the varied skills and competencies (Table 2), that were used in coaching a young adult with ADHD whose EF challenges were negatively impairing quality of life, academic success, and sense of self. No specific, validated measures were used to examine progress before and after coaching because this is a case report using data collected retrospectively from the point of care, rather than being a prospective, quantitative exploration.

Successful Coaching Outcomes

This case report demonstrates the role of HWC in helping empower an individual with ADHD to make desired behavior changes that involved improved management of ADHD and EF challenges and to achieve her broader, primary goal of resuming her graduate education. Additional strengths of this report include the client’s ability to achieve improvements in multiple functional areas (see above and Table 3) and to sustain changes beyond the 6-month mark, an important milestone often considered the beginning of the maintenance phase of change.17

The client achieved many functional and behavioral improvements once HWC was introduced into her treatment, changes that had not occurred through work with her psychiatrist alone and changes that she attributed to the coaching itself (see Sidebar: Client Perspective). However, the effects of HWC as distinct from ongoing psychiatric care were not specifically measured.

A potential limitation in broader application of this case study is the client’s initial high motivation to better manage her ADHD symptoms. Intrinsic motivation is key to behavior change17 but is not always initially present; therefore, a coach and client may need more time than illustrated in this case study to explore and develop motivation before proceeding to the action phase of change. A typical rule of thumb among coaches is that a minimum of 3 months is needed to achieve behavioral change, and sometimes more.15 In unusual circumstances, with fewer and/or simpler initial goals, HWC may be effective in fewer than 8 weekly sessions.

CONCLUSION

The integration of HWC with psychiatric care resulted in a successful intervention for improved management of this client’s ADHD and EF challenges and contributed to self-efficacy. In partnership with a health and wellness coach, the client achieved an array of positive behavior changes that resulted in her goal of being allowed to resume graduate school, which had been interrupted because of challenges associated with ADHD-related functional impairments. The key findings in this case suggest that HWC appears effective in supporting beneficial outcomes and can be a useful practice element in multimodal interventions for ADHD.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

How to Cite this Article

Ahmann E, Smith K, Ellington L, Pille R. Health and wellness coaching and psychiatric care collaboration in a multimodal intervention for attention-deficit/hyperactivity disorder: A case report. Perm J 2020;24:18.256. DOI: https://doi.org/10.7812/TPP/18.256

Author Affiliations

1 Health and Wellness Coaching Department, Maryland University of Integrative Health, Laurel

Corresponding Author

Elizabeth Ahmann, ScD, RN, PCC, NBC-HWC (eahmann@muih.edu)

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Keywords: ADHD, attention-deficit/hyperactivity disorder, behavior change, coach, collaborative, health coaching, integrative, multimodal, psychiatry, wellness coaching

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