CIinicians’ Guide To Adult ADHD Assessment and Intervention

CIinicians’ Guide To Adult ADHD

Assessment and Intervention

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Clinicians’ Guide To Adult ADHD

Assessment and Intervention

Sam Goldstein

Universityof Utah,Salt Lake City, UT Anne Teeter Ellison

University of Wisconsin-Milwaukee,Milwaukee, WI

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Thanks to George Zimmarfor his editorial assistance and vision in helping us create this text. Thanks also to Kathleen Gardner, as always, for her

editorial and technical assistance.

Sam Goldstein

This book is dedicated to adults with ADHD. To your courage. To your dignity. To your spirit. For those of you who are still looking for answers. . . I hope the ideas that follow will help.

To my husband, Phil@. Thank you for all your patience, understanding,

and support.

Anne Teeter Ellison

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The great tragedy of science-the slaying of a beautiful hypothesis by an ugly fact. Irrationally held truths may be more harmful than reasoned errors.

Thomas Henry Huxley

Although the world is full of suffering, it is also full of overcoming of it.

Helen Keller

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Contributors xv Foreword xvii Preface xix

CHAPTER

1 An Overview of Childhood and Adolescent ADHD: Understanding the Complexities of Development into the Adult Years
ANNE TEETER ELLISON

Transactional Model of ADHD: Impact of Biogenetic, Neuropsychological, Cognitive, and Psychosocial Deficits 2

Interaction of Neurobiological and Environmental Factors 6
Cognitive and Academic Findings 6
The Developmental Context: Characteristics and Associated Features of ADHD 10 Cumulative Effects of Living with a Developmental Disorder:

From Childhood to Adulthood 14
ADHD Risk and Resiliency 15
A Developmental Perspective: Implications for Treatment of

ADHD in Adulthood 18 References 19

2 Continuity of ADHD in Adulthood: Hypothesis and Theory Meet Reality

SAM GOLDSTEIN

Introduction 25
Outcome of ADHD in the Adult Years 27

CHAPTER

Contents

Contents

CHAPTER

Evaluation 35
Factors Affecting Outcome 37 Conclusion 39
References 39

3 ResearchonComorbidity,AdaptiveFunctioning,andCognitive Impairments in Adults with ADHD: Implications for a
Clinical Practice
RUSSELL BARKLEY AND MICHAEL GORDON

Disorders Comorbid with ADHD in Adults 46
Cognitive Deficits 49
Domains of Adaptive Functioning Examined in Adults with ADHD 55 Clinical Implications 61
Conclusion 66
References 66

4 The Assessment Process: Conditions and Comorbidities DIANE E. JOHNSON AND C. KEITH CONNERS

Introduction to ADHD in Adulthood: Presentation and Risks 72 Current ADHD Diagnostic Criteria, The DSM-IV 73
Practice Parameters for the Assessment of Adult ADHD 77 Making the Diagnosis of ADHD in Adults 78

Guarding Against Overdiagnosing ADHD in Adults and the Issue of Comorbidity 81 References 82

5 Clinical Case Studies KEVIN MURPHY

Case one: Assigning the ADHD Diagnosis Incorrectly Can Cause Harm 86 Case two: ADHD or Bipolar Disorder or both? 91
Case Three: ADHD with Comorbid Substance Dependence and

Conduct Disorder 95

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Contents

CHAPTER

Case four: ADHDiLD and Test Accommodations for a Professional Licensing Exam: Effective Advocacy 99

References 105

6 The Clinician’s Role in the Treatment of ADHD

KATHLEEN G. NADEAU

Overview 107
A Multi-level Approach in Treating ADHD in Adults 109 Basic Issues in Treating Adults with ADHD 111
Treating ADHD Across the Adult Life Span 113
The Challenges of the Middle Adult Years 121
Treating Adults with ADHD in Their Middle Years 122 Summary 126
References 126

7 Changing the Mindset of Adults with ADHD: Strategies for Fostering Hope, Optimism, and Resilience ROBERT B. BROOKS

The Characteristics of Adults with ADHD 128
The Unfortunate Mindset of Adults with ADHD 131 Assessing the Mindset of Individuals with ADHD 135 Coping Strategies: Helping or Exacerbating the Problem? 135 Steps for Changing Negative into Positive Mindsets 138 Concluding Thoughts About Two Men 145
References 146

8 A Model of Psychotherapy for Adults with ADHD

SUSAN YOUNG

Who Are Adults with ADHD and What Are Their Problems? 148 Psychological Therapy 150
Conclusions 158

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Contents

CHAPTER

Appendix 159 References 162

9 Pharmacotherapy of Adult ADHD

JEFFREY B. PRINCE AND TIMOTHY E. WILENS

Introduction 165
Overview of the Neurobiology and Genetics of ADHD 166
Clinical Features of ADHD in Adults 167
Assessment and Diagnosis of ADHD in Adults 168
General Principles of Pharmacotherapy of ADHD in Adults 169 Stimulants in the Treatment of Adults with ADHD 170
Nonstimulant Medications in the Treatment of Adults with ADHD 175 Clinical Strategies for the Pharmacotherapy of ADHD in Adults 179 Combined Pharmacotherapy 181
Summary 182
References 182

10 Career Impact: Finding the Key to Issues Facing Adults with ADHD

ROB CRAWFORD AND VERONICA CRAWFORD

Introduction 187
Barriers to Realistic Career Decision Making 187
Starting Out with a Realistic Picture 189
Reframing and Involvement 192
Client Involvement and Developing Self-Determination 193 The Role of the Professional as Mentor and Facilitator 194 Practical Tools and Strategies for Career Decision Making 196 Gaining Control of the Decision 198
Generating Reasonable Alternatives 200
Living with the Consequences Without Suffering 201 Managing Uncertainties and Assessing Risk Tolerance 202 Conclusion 203
References 204

CHAPTER

Contents CHAPTER

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CHAPTER

11 What Clinicians Need to Know About Legal Issues Relative to ADHD PETER S. LATHAM AND PATRICIA H. LATHAM

Introduction 205
Two Statutes 206
Individual with a Disability 206
Otherwise Qualified 213
The Right to Reasonable Accommodation 215 The Professional’s Opinion 216
Conclusion 217
Notes 217
References 2 18

12 Making Marriages Work for Individuals with ADHD

PATRICK KILCARR

Overview 220
Foundations: Setting the Initial Stages of Therapy 221 Two Therapeutic Approaches 222
Supplemental Interaction Strategies 233
Substance Abuse in the Relationship 236
Assuming Individual Responsibility 238
Summary 239
References 239

13 Families and ADHD THOMAS W. PHELAN

Introduction 241
Effects of ADHD on Home and Family 242 Parenting and Marriage 245
Good Parenting and Straight Thinking 248 Managing Family Life: What to Do 251 Summary 260
References 260

CHAPTER

xiv CHAPTER

Contents

CHAPTER

Index 293

14 Life Coaching for Adult ADHD NANCY RATEY

Claire’s Story 261
What Is Personal Coaching? 262
What Is ADHD Coaching? 262
How Coaching Helped Claire 263
Theoretical Underpinnings of ADHD Coaching 263 The Precepts of ADHD Coaching 265
The Process of Coaching 266
How Does Coaching Work? 267
Distinguishing Coaching from Other Services 272
The Power of Collaboration 273
Coaching Is Never a Substitute for Therapy 274 Issues That Can Complicate the Coaching Process 274 Finding and Choosing a Coach 275
Creating the Right Match 275
Qualities to Look For in a Coach
Conclusion 277

15 LifestyleIssues

ARTHUR L. ROBIN

Theoretical Underpinnings 280
Lifestyle Management Model 280
Understanding Strengths and Weaknesses
Maximizing Medication 283
Achieving Balance and Establishing Long-Term Goals 283 Planning to Attain Goals: The Day Planner 286 Organizing “Things” 288
Conclusion 290
References 29 1

276

28 1

Contributors

Numbers in parentheses indicate the pages on which the authors’ contributions begin.

Russell Barkley (43), Department of Psychiatry, University of Massachusetts Medical Center, Wor- cester, MA 01655

Robert Brooks (127), Harvard Medical School, McLean Hospital, Belmont, MA 02478

C. Keith Conners (7l), Department of Psychiatry and Behavior Sciences, Duke University Medical Center, Durham, NC 27705

Rob Crawford (187), Life Development Institute, Glendale, AZ 85308

Veronica Crawford (187), PART, Glendale, AZ 85308

Anne Teeter Ellison (l), Department of Educa- tional Psychology, University of Wisconsin-Mil- waukee, Milwaukee, WI 53221

Sam Goldstein (25), Neurology, Learning and Be- havior Center, University of Utah, Salt Lake City, UT 84102

Michael Gordon (43), Department of Psychiatry, State University of New York, Upstate Medical School,Syracuse,NY 13210

Diane Johnson (7l), Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710

Patrick J. Kilcarr (219), Georgetown University’s Center for Personal Development, Washington, D.C. 20057

Patricia Latham (205), National Center for Law and Learning Disabilities, Cabin John, MD 20818

Peter Latham (205), National Center for Law and Learning Disabilities, Cabin John, M D 208 18

Kevin Murphy (85), Department of Psychiatry, University of Massachusetts Medical Center, Wor- cester, MA 01655

Kathleen Nadeau (107), Chesapeake Psychological Services, Silver Spring, M D 20910

Thomas W. Phelan (241), Glen Ellyn, IL 60137 Jeffrey Prince (165), Massachusetts General Hos-

pital, Boston, MA 02114

Nancy Ratey (26l), National Attention Deficit Dis- order Association, Wellesley, MA 02482

Arthur Robin (279), Children’s Hospital of Mich- igan, Detroit, MI 48201

John Watson (xxi) 1759 E. Ski View Dr. Sandy, UT 84092

Tim Wilens (165), Massachusetts General Hospital, Boston, MA 02114

Susan Young (147), Department of Psychology, Institute of Psychiatry, De Crespigny Park, London, UK, SE5 8AF

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Controversy has always accompanied the concept and diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD), both in lay and professional circles. Perhaps resistance to the concept lies in the fact that in some sense the disorder echoes the 19th century concept of a “failure of will,” (Wil- liam James, 1890) or “moral defect,” (George Still, 1902). James had postulated that inattention was the root cause of impulsive choices, and Still first described a syndrome of normal IQ children who suffered from a “moral defect.” Their unruly be- havior, poor school work, and impulsive acts were thought to be the result of a defect in the ability to make correct (moral) choices. It was common at that time to conceptualize psychiatric disorders as the result of excess stimuli overwhelming the sen- sorium; of distraction leading to impulsive (and hence immoral) behavior.

The continuing controversy and resistance to a medical diagnosis might lie, then, in the persisting belief that the cure for a weak will is moral educa- tion, not medicine. If the controversial nature of organicity, minimal brain damage, minimal brain dysfunction, and attention deficit/hyperactivity ap- plies to children, how much more so must be the allegation that it also applies to adults! Here the field is rife with arguments against the diagnosis: hyperactivity disappears in adolescence, onset in childhood cannot be proven, pharmacotherapy is less effective in the adults, disorders of depression, anxiety, sociopathy, borderline personality, and many other psychiatric illnesses account for the putative attentional problems, and so on and on.

Conspiracy theorists harken to some of their fa- vorite explanations for the sudden burst of interest in adult ADHD, such as a collusion among aca- demics, psychiatrists, and drug companies trying to restore income lost with the advent of managed care

(if one is to believe one recent FDA maven’s assess- ment). The anti-Ritalin caucus among strident self- appointed “Centers for the Public Interest” and those worried about children “running on Ritalin,” now turn their venom on this new-fangledinvention of ADULT ADHD as further evidence of moral decline, or of an invented disorder catering to self- diagnosis among those seeking a competitive edge by performance-enhancing drugs.

Now it is surely true that there has been a shame- ful neglect of clinical and biological research on adults with the syndrome of ADHD, with the ex- ception of a few pioneers such as Paul Wender (1979) who very early saw the outlines of a distinct- ive disorder mirroring that of childhood “MBD”. But much has happened in science since those early years when the “brain” part of the syndrome was mere speculation in the absence of hard data. There is now strong evidence for the worldwide preva- lence of A D H D in virtually all countries studied. Now there is overwhelming evidence for the strong genetic heritability of ADHD; for anatomic anom- alies repeatedly detected by brilliant neuroimaging technologies, including PET, MRI, and fMRI. Alan Zametkin and colleagues (Zametkin, Nordahl and Gross, 1990) opened the doors to this new field with his demonstration in carefully assessed adult probands of ADHD children, finding clear local- ized differences from normal controls on PET scans. Converging evidence suggests that for many ADHD patients there are dopaminergic defects in receptor or re-uptake mechanisms, par- ticularly in the frontal lobes. Neuropsychological investigations also confirm the presence of persist- ing defects in executive functions, particularly for working memory, disturbances of time perception, and “forgetting to remember” (meta-memory). Symptomatic studies also detect, as it had previ-

Foreword

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ously discovered in adolescents, the emergence of a distinctive failure-related syndrome of low self- esteem, obviously associated with a lifelong history of interpersonal, academic and social failure.

As often happens in emerging sciences, prac- ticing clinicians may advance beyond the known certainties provided by empirical research and clin- ical trials. Such data are now pouring in, and new compendia of research and practice, such as the recent excellent text by another pioneer, Gabrielle Weiss and colleagues (1999), are springing up to guide both new research and practice.

Foreword

James, W. (1890). The principles of psychology. New York, NY: Holt.

Still, G.F. (1902). The Coulstonian lectures on some abnormal physical conditions in children. Lancet, 1, 1008-1012.

Weiss, M., Hechtman, L.T., & Weiss, G. (1999). ADHD in Adulthood: A guide to current theory, diagnosis and treatment. Baltimore, MD: The Johns Hopkins University Press.

Wender, P.H. (1979). The concept of adult minimal brain dys- function. In L. Bellak (Ed.). Psychiatric aspects of minimal brain dysfunction in adults. New York, N Y : Grune and Stratton.

Zametkin, A.J., Nordahl, T.E., & Gross, M. (1990). Cerebral glucose metabolism adults with hyperactivity in childhood onset. Archives of General Psychiatry, 50, 333-340.

The current volume takes a comprehensive fresh look at both the clinical and data-related issues surrounding adult ADHD. A wealth of clinical observation and new empirical data are presented here, and will hopefully inform the clinician, re- searcher, and patient alike, prompting them to put aside controversy in favor of facts, thereby insuring that adult ADHD receives the respect and attention it richly deserves as a disabling con- dition requiring compassion, informed care, and diligent research, rather than the benign neglect of the past.

C. Keith Conners, Ph.D.

Professor Emeritus of Psychiatry and Behavioral Sciences Duke University Medical Center, Durham, NC

In the fall of 2000, the wife of one of our adult patients wrote the following:

Total frustration! That’s what I feel like several times a day-or more-I hear, “I can’t find my…Have you seen…? Where is my…? If you see my…” He never picks up after himself (dirty dishes, dirty clothes, shaving cream, towels, etc.). I am tired of being the maid. If he uses the remote on the TV or the cordless phone, I have to go find them because he left them somewhere else. I more or less raised our two big girls by myself and now I am more or less raising our little boy by myself. He can’t sit still unless golf or football are on TV then he can sit still. So that is all he does at home is watch TV. Please do something for this man because after 20 years of mar- riage he is making me crazy!

This man’s self-report matched his wife’s observa- tions. He was well aware of his problems but had long given up hope that there was much he could do about them. The majority of his energy was focused at work, where he had been placed on probation a number of times. In self-report meas- ures he described his difficulty focusing on import- ant tasks and listening when spoken to, his problems with organization, his being forgetful, restless, and, in the last five years, somewhat de- pressed.

The words of this couple are echoed again and again by the individuals coming to our clinics. Although over the past 50 years the diagnostic category Attention Deficit Hyperactivity Disorder (ADHD) has been considered primarily a child- hood condition, the experiences of clinical practice teach that a significant number of children with ADHD appear to carry their impairing symptoms with them into adult life. The significant and per- vasive impairments reported day in and day out for children with A D H D has been increasingly demon- strated for a significant portion of this population during their adult years. Though the responsibil-

ities and demands placed upon adults in compari- son to children are certainly different, the consequences of these problems-impaired daily functioning-are not. What is it about the condi- tion we today call ADHD that has blinded clin- icians until just recently to recognizing that these are problems of life rather than of only childhood? Perhaps their spouses are not as vocal as their mothers, or years of impairment lead those adults with ADHD to suffer in silence, develop dysfunc- tional coping strategies, or form mindsets to deny the condition or its impact. The self-regulatory problems underlying ADHD are not outgrown. Though symptoms may wax and wane as individ- uals grow, it is a reasonable conclusion that the majority of inattentive, impulsive, and hyperactive children grow into adults manifesting many of these very same symptoms.

For the general public and perhaps a significant percentage of medical and mental health profes- sionals, it was likely reassuring to believe that the problems caused by A D H D represented a poor fit between some children and their environments. It was likely comforting for parents to hear profes- sionals tell them that not only was this a problem that would be outgrown but that by simply parenting their children differently they could change the condition. Certainly for some, this lead to strong, unwarranted feelings of guilt and to the belief that they were inadequate parents and that their failings had led to this condition. Belief is a powerful ally in the absence of fact. However, over the past ten years the belief that ADHD isjust a childhood condition has been increasingly tested. Though for some parts of the lay community and for professionals with “an axe to grind,” ADHD is still reported as a condition created by inadequate parenting or, even worse, as an illusion created by

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the marketing arms of drug companies and psychi- atric organizations, the belief that ADHD does not exist or in fact does not cause impairment through- out the lifetime has been tested and the results are clear. A significant number of individuals suffering with this condition in their childhood continue to suffer and lead lives less than their capabilities.

Perhaps another phenomena that has delayed the recognition of A D H D as a lifetime condition has been the history of associating these behaviors only with children. This is not to suggest that adults don’t act impulsively or experience difficulty sus- taining attention. They most certainly do. But for adults these symptoms historically have been con- sidered to fall clinically within the domains of other conditions, including the DSM-IV Axis I1 diagno- sis of Impulsive Personality Disorder. As far as we are aware, no one has yet to test the theory as to what percentage of adults with this condition dem- onstrate histories of ADHD. Certainly, as many researchers report including those contributing to this text, individuals with ADHD are at signifi- cantly greater risk to develop antisocial, border- line, dependent, and passive aggressive personality styles.

The earliest report of symptoms traditionally related to ADHD is credited to St. John the Bap- tist. Luke 1:41 cites John describing fetal hyper- activity: “The babe leapt in her womb.” There are also allusions in many early civilizations to this symptom as a problem of childhood. The Greek physician Galen was reported to prescribe opium for restless infants (Goodman & Gilman, 1975). Hans Hoffman’s description in 1845 of “Fidgety Phil” set the tone that wriggles, giggles, rocking, and swinging were problems of childhood (Papa- zian, 1995).Interestingly this poem also set the tone for these problems stemming from naughtiness. Naughty children are restricted from Nintendo. Naughty adults, however, are fired or sent to jail. Historically our society has had little empathy for “naughty adults.”

The notion of ADHD as a childhood condition was also reinforced by the work of George F. Still

Preface

in 1902. In describing Still’s disease, he suggested that some children have difficulty with moral con- trol because they are unable to internalize rules and limits and exhibit restless, inattentive, and overar- oused behavior. Still did not discuss the hypothe- sized outcome of these children into their adult years. He was, however, quite pessimistic, believing that these children could not successfullytransition into adulthood.

Finally, although in the late 1800s and early 1900s symptoms now considered diagnostic of ADHD were recognized as being multicausal, in- cluding the result of brain injury, the world out- break of encephalitis in 1917 and 1918 led to very different outcomes for affected children and adults. Many children who recovered from the encephal- itis presented a pattern of restless, inattentive, im- pulsive, and hyperactive behavior. The adults who recovered, however, did not so present. In extreme cases these adults became extremely catatonic and unresponsive to their environments.

Though the presence, cause, and evaluation of ADHD has been controversial, the issue of treat- ment for the condition has created by far the greatest controversy. Psychosocial treatments such as cognitive training, once considered promis- ing in directly reducing the symptoms of ADHD, are recognized as at best offering valuable interven- tions for adjunctive problems related to ADHD. Particularly in adults, problems involving self- esteem, motivation, and the development of an atypical or dysfunctional mindset can be addressed and resolved in counseling.

The greatest volume of literature in the treat- ment of ADHD has been devoted to the investi- gation of the direct benefits of psychostimulants and related medications the symptoms of ADHD. A very large, diverse, and scientifically rigorous literature has consistently demonstrated the bene- fits of psychostimulants for ADHD across the life span (for review, see Greenhill & Osman, 2000). Nonetheless, although stimulants offer excellent short-term symptomatic relief for the problems of ADHD, they have not been demonstrated in the

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factors related to this condition affecting adult out- come during the childhood years, is still very small in comparison to the body of research in this area. Nonetheless, we believe there is a consensus among practitioners that the core symptoms of ADHD affect a significant minority of our population. For affected individuals, this condition represents a poor fit between society’s expectations and these individual’s abilities to meet these expectations. This condition is distinct from other disorders of childhood and adulthood and can be reliably evaluated and effectively treated. Finally, this con- dition leads to a high financial cost for society for adults unable to transition into functional life. As Russell Barkley noted in 1991, treatment for ADHD must and will continue to be multidisci- plinary and multimodal and, in light of continuing cultural trends and societal expectations, must be maintained throughout the affected individual’s life span. Though symptoms and consequences may wax and wane, there is no cure leading to complete recovery.

The first author met John when he was nearly eighteen years of age in 1987. John was the second of his parents’ five children. At the time his siblings ranged in age between six and twenty-one years. John’s younger brother, David, had recently been diagnosed with Attention Deficit Hyperactivity Disorder. Other siblings had not experienced simi- lar problems. John’s history and functioning, des- pite his advanced intellect and achievement, was consistent for what at that time was referred to as Attention Deficit Disorder with Hyperactivity. In the following year, John participated in counseling focusing on improving relationships with family members and developing a life direction. He subse- quently served a two year mission for his church and obtained a college degree. John married and at this writing is the father of two children. He works in a managerial position with a number of siblings in a business started by his father. At 31 years of age John reports that he is happy and satisfied with his life. He continues to take medication for his condition with reported and observed benefits. He

long run to significantly alter the life course for those with ADHD. Thus, from the available, well- controlled research of children with A D H D taking medicine in comparison to those who do not, do not seem to fare significantly better into their adult lives. Outcome as described by multiple researchers appears to be related to the adverse impact of the consequences of living with ADHD. The environ- mental, educational, social, and familial factors that place all growing children at risk appear to be catalytically driven by the symptoms of ADHD, placing those with the condition at even greater risk. The biopsychosocial nature of A D H D makes it reasonable to conclude that it is the environment more than the direct treatments for ADHD that predict life outcome and course for affected indi- viduals.

We embrace the view of the symptoms of A D H D as catalytic. Place an affected individual in a good context, and ADHD may not represent a signifi- cant risk factor. But these symptoms certainly do not represent an asset as far as we believe and can demonstrate. Place them in a child living in a dys- functional family, exposed to a poor school envir- onment or other significant life stress, and ADHD likely represents a significant risk factor.

In 1988, Carey noted that it was of little import- ance if one’s theoretical orientation toward A D H D saw it as a neurobehavioral phenomenon, lack of fit between individual and environment or even a matter of cognitive style. All three factors must be considered in the intervention process. Recogniz- ing that ADHD is a biopsychosocial disorder affecting individuals differently but consistently throughout their life span shifts the focus from attempting to search for a cure to developing a balance between symptom management and the reduction of immediate problems, all the while building in resilience factors during the childhood years. It is likely that this combination of interven- tions stands the best chance of leading to positive longterm outcomes for adults with ADHD.

The research literature on this condition during the adult years, or for that matter on the risk

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participates in intermittent counseling, focusing on specific work, family and life issues as they arise. With the first author, John explored a contribution to this volume focused on sensitizing clinicians on his view of what those who profess to help adults with ADHD must know as well as his personal perception of the factors and forces that have made a positive difference in his life. His words follow.

First, let me start off by dispelling the myth that ADHD is a blessing. It is not. Nor is it an advantage, gift, or desirable in any way. Any professional perpetuat- ing this myth possesses only knowledge derived from textbooks about this condition. Such an individual lacks sufficient understanding and empathy to counsel (much less treat) afflicted individuals. Strong words, be- cause I believe strongly and want to make certain this is understood above all else. Let me expand on this by sharing an experience I had with my therapist.

My therapist has told me on many occasions that I am what every ADHD therapist hopes for in their pa- tients. I have had a very difficult time accepting this. How can someone withmy history be the standard for achieve- ment for a class of people? Perhaps my list of “haves” gives some insight into the comment. As he has reminded me I have a loving wife, wonderful children, and a fully functional family that loves me. I have no chemical de- pendencies, legal or otherwise, nor have I ever. I am financially adequate. I have a degree in marketing, and, subsequently, have a good job in which I do well and find great satisfaction. I am active, and devout in my faith. I am in general a productive reasonably well-adjusted member of society.

All of that sounds really nice. I can hear, “Oh, there’s a really together successfulguy, by any standard.” In that context I will have to gratefully agree. Unfortunately this all belies the issues that don’t come up in such a shopping list.I am horribly disorganized,both atwork and home. I have a tremendously difficult time completing the tasks before me without succumbing to major tangential dis- tractions. I find it nearly impossible to do simple things that I know are necessary, from getting places on time to completing ordinary daily tasks. My marriage gets strained to near breaking at times due to my inability to stay in a conversation or project reliably. When I d o find something that peaks my interest, all else will get pushed aside to make room for it, no matter how trivial it is. Even in print these problems don’t appear as dire as they are experienced.

Preface

My parents have been amazingly supportive and understanding through the years. This is in contrast to their desperation and frustration. From early on they knew there was a problem, but no one could give them any answers. As a child they sent me to a psychiatrist at a time when it was a financial stretch, only to have him finally conclude that, while there was a real problem, there was nothing that he could do for me! Even when times were the darkest, and my actions brought our family to the brink of chaos, their thoughts were on how to help me. I really didn’t understand all the time, effort, and patience that they put into helping me. I was a terror. Not intentionally, I just was quick to react and unaware of my own strength. I could usually pass for several years older than I actually was, and that size coupled with a faulty think-before-you-act chip resulted in lots of bruises and tears for my siblings, and conse- quently me.

In the end, structure and guidelines in a loving, caring, stimulating environment helped me above all else, due to the limits my parents helped me set and enforce. N o single element could d o it for me. I required the package. I have come to a point that I think I know wherethe answer lies, but I challenge you the professional to find the answer. I believe the secret to combating ADHD is the building of internalized barriers. An in- struction set that will not be broken. This is not easy. Pavlovian theory goes out the window with ADHD, as does reason. Even positive and negative reinforcement are of little or no use. That is the dilemma.

In my experience barriers are what insulate and pro- tect someone with ADHD. Unfortunately, those barriers are monumentally difficult to build and enforce. My request of clinicians and professionals who deal with ADHD and like disorders, is to help us (those with ADHD) learn how to construct and be guided by those barriers. Without this understanding, knowledge and insight, all therapy is hit-and-miss and lacks real, long- term efficacy.

This text represents a culmination of over forty- five years of our work in this field. Our publica- tions have included multiple texts (Goldstein & Goldstein, 1990, 1998; Goldstein, 1997; Teeter, 1998), chapters (Goldstein, 1999; Goldstein & Ingersoll, 1993) and research articles on ADHD throghout the life span. One can measure the evo- lution of a clinical condition by the publication of volumes devoted to specific aspects of the condi- tion. We believe the time has come for a text

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hope that this text will offer professionals a bal- anced view of promising techniques combined with the skilled application of treatment methods con- forming to accepted community standards and the responsible interpretation of clinical science. Know- ledgeable, compassionate professionals offer their clients and patients a powerful sense of hope by providing accurate information, understanding, support and most importantly, treatment.

Sam Goldstein, Ph.D. Ann Teeter Ellison, Ed.D.

Goldstein, S. & Ingersoll, B. Controversial treatments for chil- dren with ADHD and impulse disorders. In L. F. Koziol, C. E. Stout, & D. H. Ruben, (Eds.) (1993). Handbook of childhood impulse disorders and ADHD; Theory and practice. Springfield, IL: Charles C. Thomas.

Goodman, L. S. & Gilman, A. (Eds.). (1975). The pharmaco- logical basis of therapeutics (Sthed.). New York: Macmillan. Greenhill, L. L. & Osman, B. B. (2000). Ritalin: Theory and

practice (2nded.). Larchmont, N Y : Mary Ann Liebert. Papazian, 0 . (1995). The story of fidgety Philip. International

Pediatrics, 10, 188-190.
Still, G . F. (1902). The Coulstonian lectures on some abnormal

physical conditions in children. Lancet, 1, 1008-1012. Teeter, P. A. (1998). Interventions for ADHD: Treatment in

developmental context. New York: Guilford press.

devoted specificallyto the treatment of ADHD in adulthood. Though this text is certainly a work in progress and much research continues to be needed, it is our belief that this text offers a reasoned and reasonable review of the literature, a practical set of clinical guidelines and the obser- vations and insight of respected professionals who have devoted their careers to the scientific research and clinical treatment of this condition. It is our

REFERENCES

Barkley,R.A. (1991).Attentiondeficithyperactivitydisorder:A clinical workbook. New York: Guilford press.

Carey, W. B. (1988). A suggested solution to the confusion in attention deficit diagnoses. Clinical Pediatrics, 27, 348-349.

Goldstein, S. (1997). Managing Attention Disorders and Learn- ing Disabilities in Late Adolescence and Adulthood. New York: Wiley.

Goldstein, S. (1999).Attention deficit hyperactivity disorder. In S. Goldstein & C. Reynolds (Eds.), Handbook of Neurodeve- lopmental and Genetic Disorders. New York: Guilford press.

Goldstein, S. & Goldstein, M. (1990). Educating Inattentive Children. Salt Lake City, UT: Neurology, Learning and Behavior Center.

Goldstein, S . & Goldstein, M . (1998). Managing Attention Def- icit Hyperactivity Disorder: A Guide for Practitioners (2nd ed.). New York: Wiley.

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An overview of Childhood and Adolescent ADHD:

Understanding the Complexities of Development into the Adult Years

Anne Teeter Ellison

To understand and treat attention deficit hyper- activity disorder (ADHD) in adulthood it is import- ant to view the disorder from a developmental perspective(Teeter, 1998).According to longitudinal studies, a majority of adults with ADHD (70-85%) who were diagnosed earlier in life continue to meet the diagnostic criteria of A D H D into adolescence and adulthood (Barkley, Fischer, Edelbrock, & Smallish, 1990; Biederman, Faraone, Milberger, Guite, et al., 1996;Gittelman, Manuzza, Shenker, & Bonagura, 1985; Ingram, Hechtman, & Morgen- stern, 1999;Weiss&Hechtman, 1993).Furthermore, outcome data suggest that ADHD in childhood is a risk factor for significant psychiatric, psychosocial, and college or work adjustment difficulties later in life (Barkley, 1998a;Satterfield & Schell, 1997;Weiss & Hechtman, 1993). Lower educational achieve- ment, felony arrest, substance abuse, early and fre- quent sexual experimentation, social isolation, and

Clinician’sGuidetoAdult ADHD AssessmentandIntervention ISBN:0-12-287049–2

serious driving accidents were found at a higher rate in individuals with ADHD than in a control group (Barkley, Murphy, & Kwasnik, 1996).

In an effort to establish a developmental link for A D H D from childhood into adulthood, this chapter presents an overview of ADHD in childhood and adolescence. First, a transactional model for under- standing how biogenetic, neuropsychological, cog- nitive, and psychosocial factors interact and affect the overall adjustment of individuals with A D H D is advanced. The impact of environmental and cultural factors is also explored. Second, a developmental frameworkforADHDispresented inwhichcharac- teristics and associated features that appear early and persist into adulthood are summarized. Third, risk and resiliency factors are explored in an effort to identify variables that either enhance or impede the adjustment of individuals with ADHD. Finally, issues that impact treatment are discussed.

Cop..,vri-ght2002, Elsevier Science (USA). 1 All rights reserved

Anne Teeter Ellison

1997; Teeter, 1998; Barkley, 1997). See Figure 1.1 . for a depiction of these interrelated factors.

TRANSACTIONALMODELOFADHD: IMPACT OF BIOGENETIC,NEUROPSYCHOLOGICAL, COGNITIVE,AND PSYCHOSOCIALDEFICITS

Biogentic Findings

Family transmission of ADHD has been sup- ported by a number of studies (Faraone & Bieder- man, 1994).TherateofADHDinchildrenofparents with ADHD is higher than for the rate of ADHD in other relatives (Biederman et al., 1995). A parent with ADHD has a 57% chance of having an ADHD child. Adoption studies (Cantwell, 1975), twin studies (Gilger, Pennington, & DeFries, 1992),

Tannock (1998) asserts that “ADHD is a para- digm for a true biopsychosocial disorder, raising critical questions concerning the relations between genetic, biological, and environmental factors” (p. 65). Various transactional models of A D H D have explored the interaction of biogenetic vulnerabil- ities, executive control deficits, and the psycho- social and behavioral manifestations of the disorder (see Teeter and Semrud-Clikeman, 1995,

Biogenetic Factors h Temperament

I\; I CNS Development & Maturation

PrenataVneonataltoxins or insult Birth complications
Parental psychopathology

Lower Brain Regions/Brain Stem & Thalamic Loop
Undifferentiated activation of cortex Filtering incoming stimuli

Basal GanglidLimbic

Alerting/arousal

Thalamocortical Loop

Bidirectional Feedback Mechanisms

Prefrontal Cortex

Executive functioning
Behavioral inhibition
Initiation & regulation of motor control Conscious direction of attention Coordination of actions

Bottom-up sensory control

Relationship: Parents/Teacher

Strained 4 Oppositional
Defiant

Relationship: Peers

Isolated 4

Rejected

Ignored II

FIGURE 1.1 Transactional Model for ADHD.

Increased conduct problems Increased depression & anxiety Increased mood disorders

–_
– – – _

–_ ——

Cognitive,AttentionaI & perceptual Capacity

f
I Behavioral Social, & Psychological Manifestations or

f ADHD I Psychological

1 . An overview of Childhood and Adolescent ADHD

nos (2000) reports that a distributed circuit underlies some of the symptoms of ADHD: “At least in boys, this circuit appears to include right prefrontal brain regions, the caudate nucleus, glo- bus pallidus, and subregion of the cerebellar ver- mis” (p. 5). Studies have routinely found reduced brain volume, suggesting hypofunctioning, par- ticularly in the cortico-striatal-thalamo-cortical (CSTC) circuits. The CSTC circuit has both excita- tory and inhibitory functions, where specific re- sponses are selected and other behaviors are simultaneously inhibited. Pathways in the CSTC circuit are implicated in ADHD. “The fundamen- tal hypothesis motivating neuroimaging investiga- tions of ADHD has been that this neuronal brake does not function optimally, and that such func- tional deficits should be reflected in relevant ana- tomic abnormalities” (p. 3). It is important to keep in mind that neuroimaging technology is still evolv- ing, and much of the research has been conducted with small sample sizes and varying methodologies (Castellanos, 2000). It is likely that these circuits have other complex cognitive and motoric func- tions rather than inhibition. However, there is pro- visional support from MRI studies that circuits involved with the executive function are linked to ADHD.

Based on adult lesion studies, cognitive neurosci- entists postulate three attentional networks. The orientinghhifting network, involved with selective attention, is localized in the superior parietal lobu- les, the thalamus, and the midbrain regions. The executive network, involving the anterior cingulate and basal ganglia regions; and the alerting/arousal network, involved with vigilance, which is localized in the right frontal lobe, particularly in the superior portion of Brodmann area 6 (Posner & Petersen,

1990; Posner & Raichle, 1994). In her review of neuroimaging studies, Filipek (1996) suggests that there is initial research evidence to support these hypotheses in children. First, young adults (age 24 years)withADHDdidshowmildtomoderatecere- bral atrophy in early studies (Nasrallah et al., 1986). However,youngadultsinthestudyhadADHDwith

and international adoption studies (van den Oord, Boomsma, & Verhulst, 1994) also have identified strong genetic components of ADHD. Approxi- mately 80% of the inattention-hyperactivity-impul- sivity trait is due to genetic factors (Barkley, 1998a). While there is some evidence that extreme scores on this trait increase the genetic contribu- tion, Barkley does indicate that this later point is debatable. Environmental factors account for a much smaller percentage of the variance of the inat- tention-hyperactivity-impulsivity trait, approxi- mately 6% (Sherman, Iacono, & McGue, 1997; Silberg et al., 1996).

Persistent ADHD-into adulthood-may have a stronger familial etiology than nonpersistent ADHD (Bierderman, Faraone, Keenan, Steingard, Tsuang, 1991)). In their comprehensive genetic study, Faraone et al. (1995) found that boys with A D H D have diverse etiological risk factors, while girls appear to have a stronger familial type with strong heritability factors. Although genetic herit- ability of A D H D is high, these findings are compli- cated by the high degree of comorbid conduct, mood, and anxiety disorders found in individuals with ADHD (Biederman, Faraone, Keenan, Steingard et al., 1991).

ADHD: Advances in the Neurobiological Sciences

Neuroscientists have taken an interest in under- standing the neurobiological basis of ADHD. In his overview of lesion and neuroimaging studies, Barkley (1997) indicated that the following regions are involved in executive functions: orbital pre- frontal regions for behavioral inhibition; dorsolat- era1 prefrontal regions for working memory; and the right prefrontal regions for inhibition, particu- larly in the face of distractions. These structures and their functions are critical for understanding the neuroanatomical basis of ADHD.

In a review and analysis of neuroimaging (mag- netic resonance imaging, MRI) research, Castella-

Anne Teeter Ellison

comorbid alcohol abuse and received trials of methylphenidate during childhood that could not be ruled out as explanatory factors for the cerebral atrophy. Barkley (1998a) cautions that alcoholism, rather thantheADHD’alone,islikelytoaccountfor gross structural atrophy.

Magnetic resonance imaging studies of children with ADHD have revealed narrower right frontal measurements (Hynd, Semrud-Clikeman, et al.,

1990), and reversal of the normal left-greater- than-right asymmetry of the caudate region (Hynd, Hem, et al., 1993). A significantly smaller left caudate area accounted for the reversed asym- metry. While Castellanos et al. (1994) did not find caudate asymmetry in their sample of A D H D males who were between the ages of 6 and 19 years, other studies are consistent with the original Hynd et al. asymmetry findings. Filipek et al. (1997) did find smaller left caudate regions in ado- lescents with ADHD that also resulted in reversed asymmetry of this region compared to normal pat- terns (left greater than right). To date, inconsist- encies focus primarily on which hemisphere is smaller, because there is general agreement across studies that the caudate is smaller (Barkley, 1998a). Filipek et al. (1997) suggest that these inconsisten- cies most likely relate to methodological differences in the studies, particularly in how the boundaries of the caudate are measured and in the samples that are under study. Barkley (1998a) concludes: “more consistent across these studies are the findings of smaller right prefrontal cortical regions and smaller caudate volume, whether it be more on the right than left side” (p. 168).

Filipek (1996) summarized studies investigating differences in the corpus callosum. In general, these studies reported inconsistent findings in terms of the volume of this region. Early studies reported smaller areas of the genu, splenium, and regions anterior to the splenium (Hynd et al., 1991) and smaller volume in the splenium (Semrud-Clikeman et al., 1994). Others studies found normal volume in the sple- nium but smaller regions of the corpus callosum, particularly the rostrum and the rostra1 bodies

(Giedd et al., 1994) that connect the premotor and the supplemental motor regions. These smaller cortical areas were correlated to high hyperactivity/ impulsivity scores on the Conner’s rating scales (see Filipek, 1996, for a review). Again, differences across studies are most likely a result of the differ- ent methodologies employed (Filipek, 1996).

Other Findings of Brain Anomalies in ADHD

In a review of research over the past 25 years, Tannock (1998) reported the following findings. (1) Differences between ADHD and normal controls were found in quantitative encephalograph (qEEG) studies, and while there is little consensus on the precise nature of these abnormalities, studies did show increased slow-wave activity in the frontal lobe and excess beta activity. (2) Event-related potential (ERP) studies revealed altered EEG wave patterns (specificallyreduced P3b amplitude), which are related to difficulties in selecting and or- ganizing responses. (3) Greater uptake asymmetry in the left frontal and parietal regions based on SPECT (measures brain glucose metabolism). Fur- ther, there may be significant gender differences, where females with A D H D show greater brain metabolic abnormalities as compared to males. Di- minished metabolic activity has been found in cere- bral glucose metabolism studies using positron emission tomography (PET). Reduced metabolic activity in the left anterior frontal regions was re- lated to the severity of ADHD symptoms in ado- lescents (Zametkin et al., 1993). Zametkin et al. (1990) also found that adults with ADHD had lowered metabolic activity in the premotor and prefrontal regions of the left hemisphere that are involved with dopaminergic activity. Barkley (1998a) concludes: “This demonstration of an as- sociation between the metabolic activity of certain brain regions and symptoms of ADHD is critical to proving a connection between the findings pertain-

1 . An overview of Childhood and Adolescent ADHD
ing to brain activation and the behavior comprising

ADHD” (p. 166).

Brain Imaging for the Diagnosis of ADHD

While brain-imaging scans have been useful for investigating the neuroanatomical basis of ADHD, we are not at the point where this technology can be used to diagnose the disorder in individuals. While neuroimaging research has been used for investigat- ing groupdifferences,individualswithin groupsmay vary, so MRI scans are not diagnostic. However, there are reasons to obtain MRI scans for children with ADHD, especiallywhen one of the following is present: significant neurological abnormalities, comorbid psychotic features, atypical symptoms that do not respond to conventional treatment, or oneidenticaltwinwithADHDandtheotherADHD free (Giedd, 2000).

Executive Functioning Deficits: Disinhibition

Current research has investigated the disruption of inhibitory mechanisms via frontostriatal circuits for children with different psychiatric and neurode- velopmental disorders. While a disinhibitory model requires further validation, there is sufficient re- search that supports its basic tenets. Casey (in press) hypothesizes that

the basal ganglia are involved in suppression of actions while the frontal cortex is involved in representing and maintaining information and conditions to which we re- spond or act. Developmentally we propose that the ability to support information in prefrontal cortex against infor- mation from competing sources increases with age, there- by facilitating inhibitory control. Relevant projections from the prefrontal lobe to the basal ganglia are enhanced while irrelevant projections are eliminated (p. 22).

Deficits in organizing motor behavior, in prepar- ing for motor responses, and in the timing of re-

sponse execution have been found in children with ADHD (Schachar, Tannock, Marriott, & Logan, 1995).In fact, a number of studies have shown that externalizing behavior disorders appear also to have these deficits, specifically the inability to in- hibit, plan, time, execute, modulate, or interrupt motor responses (Mezzacappa, Kindlon, & Earls, 1999). In a study of boys ages 7 to 14 years who were unmanageable in mainstream classroom set- tings, Mezzacappa et al. (1999) investigated labora- tory measures of cognitive and motivational elements of impulse control. Children who were rated higher on externalizing behavior problems also performed more poorly on measures of impulse control. There was an age effect for some children; that is, some behaviors were resolved in adoles- cence. However, stable deficits were observed in children with externalizing behavior problems on measures of motivational control-the ability to

extinguish a previously conditioned response.
In summary, there is sufficient evidence to sug- gest that ADHD is related to abnormal functioning of cortico-striatal-thalamo-cortical circuits, and

prefrontal-striatal regions. ADHD is highly herit- able and tends to be genetically transmitted, par- ticularly in cases that persist from childhood to adolescence. Girls tend to have a stronger familial type than boys do. Tannock (1998) suggests that “the most parsimonious interpretation of the find- ings is that fronto-striatal networks may be in- volved in ADHD. Abnormalities can occur as a result of alterations in normal developmental pro- cesses (e.g., neuronal genesis, migration, synaptic pruning) that may be mediated by genetic, hormo- nal, or environmental effects or a combination of these” (pp. 83-84). Furthermore, Biederman, Far- aone, Keenan, and Tsuang (1991) conclude that strong genetic predispositions interact with psycho- social factors that influence the impact of ADHD. Although it is unlikely that optimal environments make ADHD disappear, it is possible that a “good fit” between the individual and the environment might mediate some of the negative impact of the disorder.

Anne Teeter Ellison

INTERACTION OF NEURBIOLOGICAL AND ENVIRONMENTAL FACTORS

It is important to note that even though there is strong evidence for a neurobiological basis for ADHD, there are important environmental factors that influence the way in which ADHD is expressed in individuals. Tannock (1998) cautions that

compromises within an individual’s neural substrate are important and necessary but insufficient to under- stand fully either the current or future level of function- ing of an individual. The emergenceand manifestation of ADHD and its component symptoms are likely to arise from multiple interacting factors that cannot be under- stood in isolation. Since most forms of child psychopath- ology are likely to be attributable to multiple etiologies and their interactions, the incorporation of a develop- mental-systems perspective will be an important strategy for future research (p. 68).

Environmental theories of ADHD (i.e., poor parenting, cultural tempo, etc.) have little empirical support (Barkley, 1998b). However, Barkley (1998b) suggests that “despite the large role hered- ity seemsto play in ADHD symptoms, they remain malleable to unique environmental influences and nonshared social learning” (p. 64). Environmental factors appear to play a role in the persistence of the disorder, the development of comorbid dis- orders, and the outcome of individuals with ADHD (Biederman, Faraone, Milberger, Curtis et al., 1996).

Thus, researchers and clinicians should investi- gate specific environmental factors that interact with biogenetic vulnerabilities in such a way that adjustment is compromised.

COGNITIVE AND ACADEMIC FINDINGS Cognitive-IntellectualFunctioning

Longitudinal studies of ADHD in children show that cognitive difficulties and learning disabilities (LD) continue to exist over time (Barkley, 1998a).

Decreased intelligence scores (7-1 5 points) fre- quently appear in studies, particularly with com- promised verbal intelligence, including working memory, digit span, and arithmetic deficits (Far- aone et al., 1993; Fischer et al., 1990; Hinshaw, 1992). Even though measures of intelligence may be lower, Stein, Szumowski, Blondis, and Roizen (1995) suggest that ADHD may have a more sig- nificant impact on how the child applies his or her intelligence-that is, ADHD may have a more sig- nificant impact on adaptive functioning.

Although comorbid LD may account for vari- ations in intellectual abilities for some children with ADHD, Barkley, DuPaul, and McMurray (1990) actually found that children with pure ADHD had lower abilities than children with ADHD plus LD. Hyperactive-impulsive behaviors do affect performance on IQ tests, particularly be- havioral disinhibition and executivecontrol deficits. Although it is small, 3-10% of variance in intelli- gence scores can be accounted for by symptoms of ADHD, especiallyhyperactivity-impulsivity (Bark- ley, 1998a). Intelligence may also play a significant protective factor for individuals with ADHD. See later discussion addressing resiliency in adulthood.

Academic/Work Adjustment

In an investigation of the school and occupa- tional functioning of young adults (18+ years) with ADHD, Hansen, Weiss, and Last (1999) found that they were less likely to graduate from high school than a nonpsychiatric control group. Young adults with ADHD were more likely to have obtained a GED. In a longitudinal study of young children (6-12 years of age) with hyperactiv- ity, Weiss and Hechtman (1993) followed children at age 13years (5-yearfollow-up) and at age 19(10- year follow-up). At follow-up, hyperactive individ- uals had completed less education, failed more grades, and obtained poor grades in school.

Teens with A D H D frequently d o poorly in school and typically do not perform as expected

1 . An overview of Childhood and Adolescent ADHD

orders (ODD or CD) which may have contributed to their promiscuity or their inability to fully con- sider the negative consequences of their behaviors. Hansen et al. concluded that in spite of difficulties, they are optimistic about the psychosocial outcome for young adults with ADHD, especially for indi- viduals who receive continued treatment.

In the Milwaukee longitudinal study, hyper- active young adults began having sexual inter- course at an earlier age than a comparison group (age 15 versus 16), had more sexual partners (19 versus 7), and were more likely to have conceived a pregnancy (38% versus 4%; Barkley, 1998a). They were less likely to use contraceptives and more likely to contract a sexually transmitted disease (17% versus 4%) and were more likely to be tested for HIV/AIDS. The Milwaukee study also reported high rates of driving-related difficulties, including license suspensiondrevocations (42% versus 28%), accidents where the car was totaled (49% versus l6%), and hit-and-run accidents (14% versus 2%). Driving examiners also rated young adults with hyperactivity to be more distractible and impulsive behind the wheel, which was supported by self- and parent reports of driving skills (Barkley, 1998a).

High rates of other antisocial activities were reported in the Milwaukee study, including: theft, breaking and entering, disorderly conduct, carry- ing a weapon, assault with a weapon, assault with fists, setting fires, and running away from home (Barkley, 1998a). Other studies have also reported high rates of arrest and incarceration in young adults with hyperactivity (Mannuzza, Gittelman, Konig, & Giampino, 1989; Satterfield, Satterfield, & Cantwell, 1981). In their longitudinal study of Canadian adults, Weiss and Hechtman (1993) did not report these troubling figures. While the major- ity of adults with hyperactivity do not engage in criminal behaviors, approximately 25% show a per- sistent pattern of conduct problems that may be related to the presence of comorbid antisocial per- sonality disorder (Barkley, 1998a; Klein & Man- nuzza, 1991).

given their intellectual and achievement levels (Barkley, 1998b). Children with ADHD tend to do very poorly (10-30 standard score points) on standardized achievement tests across all academic areas (Fischer et al., 1990; Semrud-Clikeman et al., 1992). In their longitudinal report of children with ADHD, Barkley et al. (1990) and Fischer et al. (1990) found that as many as 46% were suspended from school; 10% dropped out of school; 32.5% were in special education for learning disabilities, 35.8% for emotional disturbance, and 16.3% for speech language disorders. The disturbing aspect of this study was that on average this group had received extensive treatment: 3 years of medication, 16 months of individual therapy, and 7 months of family therapy in addition to 40-65 months of special education (Barkley et al., 1990).

Psychosocial and Behavioral Findings

According to Erhardt and Hinshaw (1994), chil- dren with ADHD have interpersonal problems that are among the most obvious and debilitating, par- ticularly when aggression is present. Social prob- lems range from rejection to isolation and loneliness. Measures of social adjustment also show that young adults with ADHD are more likely to have fathered children than are their non-ADHD counterparts (Hansen et al., 1999): “Perhaps ADHD boys tend to be more sexually promiscuous and/or less likely to use birth control. This finding may indicate that impulsive behavior, one of the hallmarks of ADHD, may continue into late adolescence or early adulthood. These young men may fail to consider the possible ramifications of their actions” (p. 169). The majority of young adults with ADHD in this study also had high rates of psychological problems. They were more likely to seek professional mental health servicesfor these problems than a control group without ADHD. Hansen et al. did acknowledge that the majority of young adults in their study had comorbid dis-

Anne Teeter Ellison

Behavioral Functioning: Self-Regulation

Self-regulation appears to increase between the ages of 6 and 8 years, and ratings of these behaviors predict impulsivity into adolescence (Olson, Schil- ling, & Bates, 1999). Laboratory measures of impulsivity were related to teacher and parent ratings of externalizing behavior problems. Girls who were impulsive on laboratory tasks also re- ceived high ratings on hyperactivity and delin- quency in adolescence (ages 14-17). Children who were able to select delayed rewards at age 8 years had lower rates of hyperactivity in adolescence. While gender differences were not present at age 6 years, by age 8, boys showed more impulsivity. Olson et al. (1999) found that children differ on measures of impulsivity, and these individual differences appear as “traitlike” dimensions of cog- nitive and behavioral functioning. Longitudinal re- search on childhood impulsivity is sparse, and these findings are considered exploratory. However, measures of impulsivity and inhibitory control reached significant levels of stability between ages 6 and 8. A significant level of stability was also shown for children’s preference for immediate versus delayed reward.

Cultural Context of ADHD

Prevalence rates of A D H D vary across the world, depending on the classification system employed-the DSM system or the ICD-9, Inter- national Classification of Diseases-and the geo- graphical location of the population under study. Barkley (1998a) summarized a series of inter- national studies and reported the following. (1) Anywhere from 2% up to 13.3% (in upstate New York) of children (7-1 1 years of age) in the United States may be considered. (2) A D H D rates in India are generally higher than those reported in the U.S., where 5.2-29% of children (3-12 years of age) have been diagnosed with A D H D using

DSM-I11 criteria. (3) DSM-I11 criteria were used in a study in Puerto Rico, resulting in rates of up to 9.5% of children 4-17 years of age. (4) A study of children in New Zealand reported rates of 2-6.7% using DSM- 111-R criteria. (5) In a study employing DSM-I11 and DSM-111-R criteria, 6.1-8.9% of school-age children were identified in China. (6) ICD-9 criteria resulted in rates of 4.2%, 10.9% for DSM-111-R criteria, and 17.8% using DSM-IV for children in Germany. (7) While rates in Canada ranged from 9% of boys and 3.3% of girls, it is difficult to compare these statistics because DSM symptoms were not applied. (8) The Netherlands reported the lowest rates; only 1.3-1.8% of older children (13-18 years) were classified as A D H D . Finally, children (6-17 years of age) of military families have high rates of ADHD, with 11.9-12.2% affected (Jensen et al., 1995). See Bark- ley (1998a) for a complete review.

Prevalence rates vary depending upon the diag- nostic criteria and the inclusion of Predominantly Inattentive Type (ADHD-PI) with Predominantly Hyperactive-Impulsive Type (ADHD-PHI), and Combined Type (ADHD-C; DSM-IV; American Psychiatric Association, 1994). There is great con- troversy concerning whether the Predominantly Inattentive Type of ADHD, where poorly focused attention and slow information processing is typ- ical, is actually a subtype of ADHD (Barkley, 1998b). Barkley argues that there may be import- ant differences among these subtypes of ADHD and that there may be a different developmental trajectory as well. In cases of the ADHD-PHI or ADHD-C types, hyperactivity may decline with age, and these individuals may no longer meet criteria for diagnosis in the combined or hyper- active-impulsive type. Barkley cautions that we should be careful diagnosing older individuals (where hyperactivity diminishes with age but other ADHD symptoms persist) as ADHD-PI, be- cause they do differ from those who have an early diagnosis of inattentive type. Difficulties with dis- inhibition underlie the ADHD-PHI and the ADHD-C types but not the ADHD-PI type.

1 . An overview of Childhood and Adolescent ADHD

chiatric Association, 1994). The ratio of males to females with ADHD vary depending on the study, where anywhere from 2:l to 1O:l ratios have been reported, including about 6:l in clinic- referred samples (Barkley, 1998a). There may be a lot of reasons for these differences, some of which may result from referral biases whereby males are more likely to have aggression and anti- social disorders that prompt referrals than are girls.

In a meta-analysis of gender differences in ADHD, Gaub and Carlson (1997) concluded that there were no gender differences on levels of impul- sivity, academic difficulties,social interaction prob- lems,andfinemotorfunctions.Familymembersdid not differ on measures of psychopathology, and parent educational levels did not differ. Intellectual deficitstended to be higher in girls, while hyperactiv- ity levels were lower, and there were fewer signs of aggression, conduct problems, and defiance (exter- nalizing disorders). These differences were depend- ent on the study samples-clinic versus community. Boys and girls tended to be more similar in clinical samples. In community-based samples, girls with ADHD were less aggressiveand had fewer internal- izing disorders than males.

In the largest study of girls to date, researchers found that girls showed similar rates of depres- sion (17%), anxiety (32%), and bipolar (10%) dis- orders that were comparable to earlier studies with boys (Biederman, et. al., 1999). Girls had lower rates of conduct disorders (10%) and oppositional defiant disorders (33%) and had slightly lower intellectual, reading, and math scores (still within normal range) compared to boys. Treatment/ interventions needs were also similar for girls and boys with ADHD, including the need for tutoring, special education, counseling, and medication. It will be interesting to determine whether the figures derived in the Safer and Malever (2000) survey of children in Maryland hold up in other states. That is, do girls also receive less medication treatment for ADHD across the country?

In the United States, controversy over the assess- ment of A D H D in culturally diverse populations exists. Caution is recommended due to the lack of adequate norms on common rating scales that are frequently used. Reid (1995) investigated the repre- sentation of minority children on various measures available for assessing ADHD, and found that only two measures are adequate-the Children’s Atten- tion and Adjustment Scale and the Attention Deficit Disorders Evaluation Scale (ADDES). Reid sug- gests using multimethod approaches, particularly functional approaches, to better assess children from diverse backgrounds. These practices involve behavioral assessment of the problem, intervention planningandimplementation,progressmonitoring, and intervention revision. “If a child continues to evidence problems related to ADHD-such as difficulties in attention deployment or impulse con- trol-then a diagnosis of A D H D may be indicated” (p. 556).

In a statewide review of children receiving stimulant medication in the Maryland Public Schools, Safer and Malever (2000) data on “non- white student groups (black, Hispanic, Asian, and native American) reveal that all have a com- paratively lower treatment prevalence for ADHD medication than white students” (p. 537). Based on a review of the literature, Safer and Malever found that black youth do exhibit ADHD features on rating scales at rates similar to white children. Fur- ther, cultural factors may explain some of the vari- ation in treatment rates, particularly the low level of stimulant treatment for black high school stu- dents. Data from this sample also showed that medication treatment for ADHD was higher in males than in females.

Gender Differences in Our Understandingof ADHD

In general, boys are more likely to have ADHD than girls, according to DSM-IV (American Psy-

Anne Teeter Ellison

THE DEVELOPMENTAL CONTEXT: CHARACTERISTICSAND ASSOCIATED FEATURES OF ADHD

Let me start out by saying that criteria from present diagnostic systems (i.e., the Diagnostic Statistical Manual-IV) are not adequate for adults (Ingram et al., 1999). (See Chapter 4 for an in- depth discussion of assessment and diagnostic issues for adults with ADHD.) The clinical picture of ADHD varies over time, with some symptoms becoming more or less important depending on the developmental age of the person (Ingram et al., 1999; Teeter, 1998). Table 1.1 summarizes major similarities and differences among adolescents and adults with ADHD and shows how characteristics of ADHD vary across the life span. Also see Gold- stein and Goldstein (1998) for a review.

ADHD Characteristics in Early and Middle Childhood

Early signs of inattention, hyperactivity, and impulsivity in children contribute to difficulties with self-esteem,learning problems, academic diffi- culties, and underachievement (Barkley, Fisher, Edelbrock, & Smallish, 1990). Psychosocial diffi- culties often result in peer rejection because of awkward or inappropriate social interactions (Milich & landau, 1989; Milich, Landau, Kilby, & Whitten, 1982). Language difficulties may further contribute to problems in communication, while impulsive, negative, and aggressivebehaviors inter- fere with social interactions. Isolation from peers may further reduce the opportunity to develop effective interaction and coping skills that promote social effectiveness (e.g., frustration tolerance, anger control, negotiation, and compromise).

The academic and learning difficulties that are common for children with ADHD at this age appear related to difficulties with work completion and ac- curacy rates (Barkely, 1998a) and to poor persist-

enceandmotivation ondifficulttasks(Milich, 1994). Organizational deficitsare frequent (Zentall, Harper & Stormont-Spurgin, 1993),and deficitsin self-con- trol result in impulsive, careless mistakes (Teeter, 1998). Off-task, out-of-seat, and noncompliant be- haviors also contribute to school adjustment diffi- culties (Weiss & Hechtman, 1993). An inability to maintain behavioral responses (i.e., poor persistence and vigilance) interferes with classroom behaviors, especially when tasks are repetitive or boring. These difficultiescomeatadevelopmental stagewhenthere are more demands on the child and classroom ex- pectations call for sustained attention, effort, and goal directedness. Unfortunately, these demands tap into the very areas that are most difficult for children with ADHD; thus the impact of the dis- order can be quite devastating.

Many children with ADHD are exquisitely at- tuned to the fact that they are not performing up to their peer group, that they are not meeting the expectations of important adults in their lives, and that they are not well liked by their peers. This cycle creates self-doubt and a lack of confi- dence in one’s abilities, which may result in depres- sion. Children at this age may disengage from the learning environment to avoid being humiliated by failure or the negative comments that come from teachers and peers when they “screw up.” This withdrawal further exacerbates the learning diffi- culties that are present, and children at this age may fall hopelessly behind in their academic skills. Because later learning draws on foundational skills, these difficulties may become even more prominent during adolescence. This cycle creates a high risk for school dropout, school failure, and academic underachievement that are common in adolescents with A D H D (Barkely, Fisher, Edel- brock, & Smallish, 1990).

ADHD and Comorbidity

Children with ADHD are at risk for comobid disorders, including oppositional defiance disorder

1 . An overview of Childhood and Adolescent ADHD

sample of children with ADHD/PI and ADHD/C, according to Chang et al. (in press). Children with ADHD/C had more nonperseverative errors than ADHD/PI, which may reflect attentional prob- lems and acquisition errors (Klorman et al., 1999). Performance on the Wisconsin Card Sort Test did not discriminate groups, while scores on the Tower of Hanoi (TOH) were differentially sensitive, in- cluding rule violations. The EF deficits found in the sample of children with ADHD/C were not re- lated to intellectual abilities. But EF deficits were found in the ADHD/C and the ADHD/PI plus R D groups.

ADHD Characteristics in Adolescence

Unfortunately, research on ADHD in adoles- cence is sparse. However, even though we have only a handful of studies that address this issue, several are methodologically strong and offer us an excellent picture of the disorder during this stage. Early studies of ADHD explored the extent to which children simply outgrew the disorder over time (Ingram et al., 1999). Weiss and Hechtman (1993) initially found that 25% of children with ADHD could not be differentiated from normal controls in adolescence and that 30% of adults were not signifi- cantly different from a control group. Studies sug- gest anywhere from 43% to 80% of children continue to show ADHD into adolescence (Barkley, Fisher, Edelbrock, & Smallish, 1990; Biederman, Faraone, Milberger, Guite, et al., 1996; Biederman, Fara- one, Taylor, et al., 1998; Cantwell & Baker, 1989; Fischer, Barkely, Fletcher, & Smallish, 1993; Weiss & Hechtman, 1993).What is most disturbing about this picture is the growing evidence of the wide- spread effects of ADHD on all aspects of life- academic, psychosocial, behavioral, and emotional for a majority of individuals. Again, Table 1.1 sum- marizes major differences among adolescents and adults and shows how characteristics and features of A D H D vary across the life span.

(ODD) and conduct disorder (CD) (Barkley, 1998a; Faraone, Biederman, Jettson, & Tsuang, 1997; Eir- aldi, Power, & Maguth Nezu, 1997), depression, anxiety, and bipolar disorders (Biederman, Far- aone, Mick, Moore, & Lelon, 1996; Perrin & Last, 1996), and reading disabilities (Semrud Clikeman et al., 1992). Furthermore, the severity of ADHD symptoms may predict comorbity (Barkley, 1998a).

ADHD Subtypes: Comorbidity and Associated Executive Function(EF) Deficits

There is growing evidence that the subtypes of ADHD may have different risk factors associated with the disorder: (1) ADHD predominantly in- attentive type (ADHD/PI); (2) ADHD predomin- antly hyperactive-impulsive type (ADHD/HI), and (3) ADHD combined type (ADHDK). While hyperactive and inattentive types cannot be distin- guished by cognitive deficits alone (Lahey & Carl- son, 1992), Barkley (1998a) reports that children with ADHD/C perform more poorly on the Con- tinuous Performance Test and the Wisconsin Se- lective Reminding Test. Children with ADHD/PI also showed poorer perfomance on the Weschler Coding subtest.

A D H D children who show signs of physical ag- gression (Sequin, Pihl, Tremblay, Boulerice, & Harden, 1995) and conduct disorders (Giancola, Mezzich, & Tarter, 1998) also appear to have separ- ate risk factors, particularly related to greater execu- tive deficiencies. A D H D children with reading disabilities (RD) also appear at risk for cognitive deficits, including phonological, lexical decoding, rapid naming, and conceptual-reasoning deficits (August & Garfinkel, 1990; Shaywitz et al., 1995). Klormanet al. (1999)alsofoundthatchildren(7%to

13%years of age) with ADHD with hyperactivity- impulsivity had deficient E F deficits on tasks requir- ing planning, working memory, and spatial skills. Paired-associative learning was impaired for a sub-

Anne Teeter Ellison

Signs and symptoms

Attentional difficulties

Motor problems

Impulsivity

Emotionality, temper, &mood

Correlates at developmental stages Childhood/adolescence

Adulthood

Stress intolerance

Short attention span, not sticking to things; unmotivated, difficulty following instructions in school; can’t listen for long, can’t remember, everything half finished in home & school; does best with adult supervision; attention most impaired for boring tasks; attention is good for novel & interesting tasks; attention not under “social control”; off-task, restless, vocal behavior during academic tasks

Fidgety; drums fingers; kicks feet; restless; overtalkative-“motor mouth”; impaired coordination; poor handwriting; poor eye-hand coordination in sports; soft neurological signs (e.g., clumsy); prolonged reaction times; needs to talk more, move more, & interact with stimulating environment

Difficulty delaying gratification; low frustration threshold; impatient; blurts things out in class or interrupts; reckless, with little concern for consequences; acts before thinks; frequent driving accidents; high risk-taking behaviors; teens less likely to use birth control

Labile moods-dysphoric to overexcited; disruptive disorders when history of early aggression, antisocial problems; unpleasurable stimuli provoke temper; short fuse; may have history of fighting (more typical of conduct disorder); difficulty experiencing pleasure; doesn’t seem happy; may be demoralized because of failure, negative feedback from adults, constantly disappointing adults; may have biological factors linked to self-esteem & mood; may engage in sensation-seeking behaviors as teen (e.g., drinking & driving, drug use); ADHD risk for depression & anxiety

Difficulty staying with things under pressure; less tolerant of low-arousal tasks; may be an optimal arousal level

Particularly problematic for college students; other adults may not complain about attention problems-self-select jobs with low demand for constant attention, difficulty keeping mind on reading; concentrates when necessary for 5-10 minutes; rarely sits through a TV show; trouble listening to conversations; interrupts in social interactions; may learn to minimize distractions; misplaces little things (e.g., keys, wallets)

Many remain hyperactive, fidgety, & restless; uncomfortable sitting still; dislike being inactive; can’t relax; rather stand than sit; forced immobility produces anxiety; fidgety and foot movements; “cross-knee’’ foot jiggle or foot tap; still poor in sports & handwriting

Greater opportunity to inflict serious self-damage; acts on spur of moment; makes decisions without thinking; little reflection (e.g., quits job, marries or divorces hastily)

Similarlabilityseeninchildren;moodshifts,‘‘ups’’& “downs” common throughout day; spontaneous roller coaster ‘‘ups’’ are reduced in adults, but “downs” persist; “downs” described as boredom or discontentment; not like major depressive disorder; constantly getting into demoralizing situations because of academic, work, or interpersonal problems; explosive tempers may calm down quickly; always seems irritable; destructive in relationships; anger seems provoked by stimulus.

Reports being overactive to normal stress or pressure; inappropriate response to ordinary demands; can’t handle things out of the ordinary; describes self as “stressed out,” “discombobulated,” or “hassled’; anxiety with stress creates problems, and becomes more impulsive, disorganized and less competent

Note:

See Goldstein & Goldstein (1998) and Teeter (1998)

TABLE 1.1

Signs and Symptoms to Look For in Adolescents and Adults with ADHD

1 . An overview of Childhood and Adolescent ADHD

low probability of A D H D with C D and/or ASPD in relatives for those individual with ADHD and no CD.

Faraone et al. (1997) found that relatives of the ADHD +ODD group had about the same risk for disordersasdidtheADHD-onlygroup.TheADHD +ODD group was not that similar to the ADHD + CD group. Furthermore, children with ADHD + ODD who did not develop CD by adolescencewere nosologically distinct from those individuals who did develop CD. That is, the ADHD +CD group had earlier onset of ODD and had an increased risk for mood and anxiety disorders, more comorbid psychiatric disorders, and more initial ODD symp- toms (Biederman, Faraone, Milberger, Garcia Jetton, et al., 1996). In conclusion, “although a large majority of CD children have prior histories of ODD, many ODD children do not go on to de- velop CD” (Faraone, Biederman, Jeffson et al.,

1997,p. 298).
Second, there may be important differences

among children with ADHD who are followed into adolescence versus adolescents who are first referred for ADHD. Comorbid disorders are a challenge at younger ages, but may be even a bigger issue for adolescents. Biederman et al. (1998) hy- pothesize that teens with ADHD and depression may not receive a diagnosis of ADHD if their symptoms are viewed to be secondary to the de- pression: “A reluctance to diagnose comorbid con- ditions could thereby lead to an underdiagnosis of ADHD in adolescence” (p. 306).

In their study of 260 males between the ages of 6 and 17 years, Biederman et al. (1998) found that symptoms and associated features in adolescent ADHD were the same as for ADHD found in youn- ger children. Adolescents with A D H D had higher rates of CD, ODD, mood disorders, and anxiety disorders. Bipolar and substance abuse problems were similar for both the older and the younger groups of A D H D individuals. Family history was significant; that is, adolescents with ADHD had a more remarkable family history of ADHD than did children with ADHD. When ADHD persists into

In their longitudinal report of symptoms into adolescence, Weiss, Minde, Werry, Douglas, and Nemeth (1971) found that adolescents demon- strated more academic difficulties, significant antisocial problems, and poor self-esteemwith con- tinued impulsivity, emotional immaturity, distract- ibility, and lower hyperactivity. Furthermore, 70% still have ADHD, with significant academic, social, and emotional difficulties (Hechtman, 1999). “Children who also have aggression and/or con- duct disorder generally have more negative out- come, and stimulant treatment does not appear to significantlyaffectthis outcome” (Hechtman, 1999, p. 17).

Teens with ADHD have numerous challenging difficulties. To summarize the most prominent aspects of ADHD in adolescence: First, the pres- ence of comorbid disorders becomes a paramount feature and complication for the majority of teens with ADHD. Although young children with ADHD do show high rates of comorbitity (espe- cially LD and ODD), teens with ADHD appear to be highly susceptible to serious psychiatric and emotional disorders as well (Barkley, 1998a; Bark- ley, Fischer, Edelbrock, & Smallish, 1990). For example, 59% were also diagnosed with ODD and 43% had CD according to Barkley et al. (1990). There appear to be important factors related to the co-occurrence of ADHD with other disorders that need to be addressed in treatment. In a longi- tudinal study, Faraone et al. (1997) found the following. (1) Relatives of ADHD groups were more likely to have ADHD and ODD than were normal probands. (2) Rates of CD and antisocial personality disorder (ASPD) were related to ADHD +CD probands only. (3) ADHD with ASPD was accounted for by marriages between ADHD and antisocial spouses. (4) ADHD and antisocial disorders occurred in the same relative more often than expected by chance alone. Al- though Faraone et al. (1997) conclude that ADHD +CD is a familially distinct subtype, they cannot determine whether the familial etiology is genetic or environmental. In general, there was a

adolescence, there is more likely to be a higher risk factor for familial ADHD. Biederman et al. (1998) caution that it is important for clinicians to pay attention to the age of onset of ADHD when assess- ing comorbid disorders. “For example, a depressed 5-year-old having subthreshold symptoms of ADHD may be at risk for the full ADHD symptoms in later years. In contrast, because adolescents have passed through the age of risk for ADHD, we will be more confident about negative diagnoses of that disorder” (p.311).Itiscriticalthatcliniciansinvesti- gate comorbidity in adolescents, due to the risk for suicide in teens with bipolar disorders, conduct dis- orders, and ADHD (Brent et al., 1988).Finally: “An adolescent with ADHD who presents with acute signs of anxiety, depression, bipolar disorder, or substance abuse will likely receive a diagnosis and treatment for the acute disorder. Although it makes sense to treat the acute condition, that course of action should not deter clinicians from making comorbid diagnosis of ADHD if confirmed by the patient’s history and current condition. Once the acute problem has cleared, the ADHD can then be treated as well” (Biederman et al., 1998,p. 312).

Third, ADHD adolescents who also have signs of a social disability (SD) are at a greater risk for mood, anxiety, disruptive, and substance abuse disorders than comparison boys with ADHD and no SD (Greene, Biederman, Faraone, Sienna, & Garcia-Jones, 1997). In this 4-year longitudinal follow-up of boys with ADHD, the presence of SD predicted poor social and psychiatric outcome, particularly substance abuse and CD. Although the etiology of this relationship is not well understood, the construct of social disability needs to be more fully explored. Greene et al. (1997) conclude: “These findings suggest that assessment of social functioning might be useful in identifying sub- groups of children with ADHD at very high risk for complicated course and poor prognosis. Such early identification may permit this targeting of scarce societal resources toward those at greatest need to receive services” (p. 764).

Anne Teeter Ellison

ADHD Characteristics in Adulthood

There is compelling evidence showing that ADHD does not disappear for a majority of adults who have been diagnosed early in life. However, there is evidence that “diagnostic difficulties con- tribute to a lack of consistency in adult ADHD diagnosis” (Ingram et al., 1999, p. 244).

In their longitudinal study, Weiss and Hecht- man (1993) reported high rates of social interaction problems, particularly in male-female relation- ships. “It should not be surprising then that the greater self-esteem problems of ADHD children noted in adolescence continue and may even worsen as they reach adulthood” (Barkley, 1998a, p. 208). In fact, Hansen, Weiss, and Last (1999) found that young adults with ADHD were more likely to have fathered children, to need mental health services, and to report psychological prob- lems than were control males.

CUMULATIVE EFFECTS OF LIVING WITH A DEVELOPMENTAL DISORDER: FROM CHILDHOOD TO ADULTHOOD

There is no doubt that a substantial number of children and adolescents continue to show ADHD symptoms into adulthood. How does the presence of chronic symptoms over a lifetime affect adults? There may be a host of factors quite different from those for acute disorders that complicate the treat- ment of adults with chronic disorders like ADHD. As clinicians and researchers, we need to consider the effects of chronic academic underachievement, loss of social opportunities, and the presence of comorbid disorders that appear to increase with age. These factors complicate the picture of ADHD in adults and suggest the need for multi- modal treatment plans to increase the adjustment of adults with ADHD.

1 . An overview of Childhood and Adolescent ADHD

Academic underachievement may create a host of adult outcomes that affect the individual’s career choices and work enjoyment and satisfac- tion. Although almost all adults with A D H D are gainfully employed, according to longitudinal stud- ies (Manuzza et al., 1993), they may experience more job stress. Employers do rate adults with ADHD in negative terms on measures of meeting job expectations, getting along with supervisors, working independently, and completing work tasks. Many of these problems appear directly re- lated to their ADHD symptoms, particularly rest- lessness, impulsivity, and poor concentration. Adults with ADHD have a higher tendency to change jobs and/or to work two jobs to adjust to feelings of restlessness and nervousness that they experience on the job (Borlund & Hechtman, 1976). The good news about the employment pic- ture is that many adults with ADHD own busi- nesses (Manuzza et al., 1993) and are able to select job settings that are more conducive to their unique work styles. However, we don’t know enough about the emotional stress that adults with ADHD experience on a daily basis because of problems keeping things organized, staying on top of work demands, keeping emotions in check, and dealing with the pressures of dead- lines.

How does social isolation or relationship diffi- culties early in life affect the development of effec- tive coping skills (i.e., frustration and anger management) that are needed to successfully build meaningful relationships in adulthood? Do individuals with ADHD miss out on important experiences through which one learns the give- and-take of relationships? D o the symptoms of ADHD-emotional reactivity, impulsivity- make social interchanges more emotionally charged and stressful? What is the psychological cost of a history of social isolation in childhood and/or adolescence? These issues should be ex- plored when assessing and treating adults with ADHD.

ADHD RISK AND RESILIENCY

Some studies suggest that the persistence of ADHD into adulthood is related to comorbidity of other psychiatric disorders, particularly conduct or aggressive disorders (Gittelman et al., 1985;Tay- lor, Sandberg, Thorley, & Giles, 1991).In an investi- gation of factors related to early and late remission of ADHD, Biederman, Faraone, Milberger, Curtis et al. (1996) found that only a small percentage of children with A D H D remit in adolescence (15%). About 50% of this group showed remission of sym- ptoms in childhood, and the other half did so in adolescence. Biederman, Faraone, Milberger, Cur- tis et al. (1996) found that “predictors of persist- ence were familiality of ADHD, psychosocial adversity, and comorbidity with conduct, mood, and anxiety disorders” (pp. 347-348).

In earlier studies, Faraone and Biederman (1994) found that individuals with familial A D H D may be a subgroup with higher risk factors, including significant reductions in brain metabolic activity (Zametkin et al., 1990) and more neuro- psychological impairments (Seidman et al., 1995). It is likely that persistent ADHD triggers a host of family psychosocial adversity as well. Parental psychopathology and first-degree relatives have higher rates of oppositional defiant disorder (ODD), conduct disorder (CD), antisocial person- ality disorder (ASPD), depression and anxiety dis- orders (Biederman, Faraone, Mick et al., 1996; Morrison1980). While it is difficult to separate genetic from environmental risk factors in these families, adversity and stress appeared to be signifi- cant predictors of persistence (Biederman, Far- aone, Milberger, Curtis et al., 1996). These factors most likely interact where biogenetic vulner- abilities combine with family adversity, including conflict, expressiveness, family cohesiveness, low socioeconomic status (SES), large family size par- ental criminality, maternal mental illness, and severe marital discord, to create poor adult out- come.

Comorbidity of psychiatric disorders is also a significant predictor of persistence of A D H D into adulthood. While evidence of comorbid ODD, CD, and aggression are predictive of poor outcome, Bie- derman, Faraone, Milberger, Curitset al. (1996) also established a link between persistence and mood disorders (i.e., anxiety and depression). Adults with A D H D also have higher rates of comorbid dis- orders than do non-ADHD adults (Biederman, Faraone, Mick, et al., 1995). These disorders inter- act with ADHD to produce a more impaired and persistent form of ADHD. Although children who show early remission of A D H D had lower rates of aggression and CD-related problems, this was not the case for late remission. Early remitters did not differ from late remitters or those with persistent ADHD on presenting symptomology, cognitive and learning deficits, and the need for interven- tions. However, familial adversity and comorbidity were important factors predicting adult outcome. Children who do not have these risk factors appear to have a more positive outcome.

Lambert, Hartsaugh, Sassone, and Sandoval (1987) found that cognitive and behavioral matur- ity was a risk factor for later outcome and that the still-hyperactive group in their study (43%) was immature on both dimensions. The residual group (37%) still had persistent learning, behavioral, and emotional problems, but this group was no longer receiving medical treatment for hyperactivity. Al- though this later group showed signs of behavioral maturity, they did still evidence signs of cognitive immaturity. Both groups required more treatment than the subjects (20%) who showed no problems at follow-up.

Poor adaptive functioning may impact adoles- cent and adult outcome. Barkley (1998a) states: “Adaptive functioning is frequently used to refer to the child’s development of age-appropriate motor skills, self-help abilities (i.e., dressing, bathing, and feeding), personal responsibility and independence (chore performance, trustworthy, use of money, eti- quette), and peer relationships” (p. 98). Despite average intelligence, many children with ADHD

Anne Teeter Ellison

have low adaptive abilities. Numerous longitudinal and cross-sectional studies report that children with ADHD have poor adaptive abilities compared to age peers (Barkley, Fischer, Edelbrock, Smallish et al., 1990; Greene et al., 1997; Stein, Szumowski, Blondis, & Roizen, 1995). Furthermore, Barkley (1998a) suggests that “the greater this discrepancy between IQ and adaptive functioning, the greater the impairment the ADHD child is likely to experi- ence and the more likely he or she is to experience comorbid disorders” (p. 99). Specifically, Green et al. (1997) found that youth with ADHD with the greatest degree of social or adaptive impairment are more likely to have comorbid disorders at follow-up.

Traumatic events in one’s life can also drastic- ally alter the course of ADHD and exert additive risk factors. Weiss (1999) described a case study of a youngster whose A D H D was complicated by a stressful life event:

Crises in the lives of troubled children are more common than in the lives of healthy children. When they occur they may affect the course of the disorder and its treatment. For example, Willy was an 8-year-old boy treated for ADHD and doing well on a given dose of methylphenidate. One night his father (an adult with ADHD) lost his temper with his son and locked him out of the house. Willy ran away, was picked up by a child molester, and had unfortunate experiences over several days until found by the police. After this episode Willy’s course of ADHD worsened, and his normal dose of methylphenidate no longer improved his core symptoms. He also developed an adjustment disorder with anxiety and depression.. . . [qt took several years before the child was closer to his previous level of functioning (pp. 3-4).

ResiliencyFactorsThat Moderate the Impact of ADHD in Adulthood

Which factors help protect or moderate the impact of ADHD? Are there child or adolescent fac- tors that reduce the negative effects of ADHD through the lifespan? Three factors appear to be relevant to these questions: (1) child factors, includ- ing the severity of ADHD, the presence of comorbid

1 . An overview of Childhood and Adolescent ADHD

family risk factors include socioeconomic status (SES), family instability (i.e., divorce and/or separ- ation), parental psychopathy, and alcoholism (Barkleyet al., 1990;Biederman et al., 1996;Hecht- man et al., 1984; Satterfield & Schell, 1997). Low SES alone does not appear to be the most salient risk factor; it is the accompanying psychological and emotional strain that is placed on families that is more predictive of poor outcome.

There appears to be aninteraction between family stability and ADHD, “whereas the families of chil- dren exhibiting a more negative outcome deterior- ated over time” (Ingram et al., 1999, p. 247). Even though causality cannot be implied, the impact of ADHD on families can be disruptive, while at the same time strong family cohesion and parental sup- port constitute significant resiliency factors for many individuals with ADHD. For case studies see Chapter 5for examples of how family support can be critical to the overall adjustment of individuals with ADHD.

Finally, treatment issues can also predict adult outcome. To date, there are some significant trends that can be gleaned from studies investigating the effects of treatment on long-term outcome for indi- viduals with ADHD. These are reviewed next.

Does EarlyTreatment Affect Adult Outcome?

It is difficult to determine whether treatment per se increases positive outcome for individuals with ADHD. Initial longitudinal studies showed that boys with hyperactivity who received multimodal treatment (e.g., individual and/or group therapy for the child and parent, with stimulant medica- tion) that was designed to meet their individual needs was related to better outcome (Satterfield et al., 1981). On the other hand, in a series of longitu- dinal reports, Barkley and colleagues (Barkley et al., 1990; Fischer et al., 1990) found that even with the use of extensive educational and mental health treatment, most youth with hyperactivity continue

disorders, and the child’sintellectual capabilities; (2) the family environment; and (3) treatment (Ingram et al., 1999).

First, Ingram et al. (1999) suggest that adaptive functioning and coping skills may provide a pro- tective function or may predict poor prognosis or adult outcome. “Individual characteristics such as IQ, comorbidity, oppositionality, aggression,. . . emotional state, and peer relationships can act singly or in combination to influence the adaptive functioning and outcome” (p. 246). A number of child factors appear to predict outcome, especially antisocial behaviors (Hechtman, 1996), C D and ODD (Satterfield & Schell, 1997), and depression, anxiety, and mood disorders (Biederman, Faraone, Taylor, et al., 1998). Comorbid antisocial behavior disorders are particularly insidious and are associ- ated with higher arrest and substance abuse rates than are found in individuals with ADHD who do not exhibit conduct problems. Biederman and col- leagues (1995) found a subgroup of newly referred adults who also exhibited recreational drug and alcohol abuse. Ingram et al. (1999) suggest that this subgroup may be oversampled and may ac- count for some studies that report increased drug and alcohol use in hyperactive youth. Comorbid disorders (e.g., anxiety) need to be considered and addressed when deciding on treatment options, for they do reduce the efficacy of stimulant medication (Pliszka, 1987).Adults who abuse drugs or alcohol also need to address abuse issues separately from treatment for ADHD.

Low IQ is another important factor related to the development of comorbid disorders and treatment outcome in individuals with ADHD. Aman (1996) foundthatlowIQwasrelatedtopooradaptiveskills and to impaired functioning over time. There may also be gender differences that are important when considering the effects of cognitive deficits and ADHD; Pearson et al. (1996) found that girls with low IQ (mental retardation, MR) are at greater risk for ADHD than are non-MR groups.

Family factors do affect adult outcome and can serveto buffer the impact of ADHD. Inmost studies,

to experience significant academic, behavioral, and social problems in adolescence. In fact, “stimulant medication does not seem to have significantly affected” the educational, psychosocial, and behav- ioral outcome of ADHD from childhood to ado- lescence (Hechtman, 1999, p. 24).

Even though social skill deficits appear to be an associated feature of ADHD, social skills training has not proven to be an effectivetreatment approach to date. “Teaching them additional skills is not so much the issue as is assisting them with the perform- ance of the skillsthey have when it would be useful to do so at the points of performance where such skills are most likely to enhance the child’s long-term social acceptance” (Barkley, 1998b,p. 71).

Although these studies may seem overly pessim- istic, there are some encouraging outcomes when looking at individual case studies. In my work with teens and young adults with ADHD, they typically report that they have developed important coping and adaptive skillsthat helped them become success- ful either in college or in their jobs. In many in- stances, these young adults were in therapy or treatmentatdifferenttimesoftheirlivesfordifferent problems. Initially, they and their families sought out and received fairly intensive interventions for academic, behavioral, and/or social problems. Medication in combination with other treatments (e.g.,family/parenting,schoolaccommodations,be- havioral and psychosocial interventions) did allevi- ate symptoms of ADHD. However, singletreatment approaches did not adequately address all their needs, and therapy at one point in their development did not inoculate them from problems in later stages of life. Early treatment did seem to help them de- velop coping mechanisms that could be built on for later developmental challenges. Clinicians should prepare adolescents and families for this inevitabil- ity-that treatment for ADHD may be a lifelong process. In most instances, the young adults I have worked with have continued to use medication and have continued to learn more about their disorder. They have sought out and received psychological or psychiatric assistance at different times in their life

Anne Teeter Ellison

into adulthood and have benefited from appropriate support.

It is possible that we need to think differently about treatment efficacy when it comes to evaluat- ing the effects of interventions on individuals with disorders that create persistent, lifelong problems. We need to adopt a developmental model of treat- ment where individuals at different stages of life periodically check in with professionals, to develop coping or adaptive skills to get through pressing problems of the moment. In many ways, our ther- apyhntervention models leave the impression that short-term treatment should provide a buffer through the life span. This perspective is too sim- plistic and unrealistic for ADHD. We may be set- ting up unrealistic expectations that treatment in childhood or adolescence will help individuals de- velop all the adaptive skills needed throughout adulthood. There is little clinical evidence for this, and far too few empirical studies have addressed these issues. We do know that we cannot cure individuals with ADHD, that many of the symp- toms are persistent (i.e., impulsivity, inattention, disinhibition), and that when treatments (i.e., medication or other behavioral, psychosocial strat- egies) are removed, symptoms reappear. What we do know is that the effects of ADHD can be ameli- orated when combined treatments are employed, and individuals can develop effective and powerful self-management and adaptive skills.

A DEVELOPMENTAL PERSPECTIVE: IMPLICATIONS FOR TREATMENT OF ADHD IN ADULTHOOD

First, we need to adopt a developmental per- spective when considering ADHD and treatment. There is no evidence that a single treatment ap- proach cures ADHD, nor does early treatment fully mitigate the effects of A D H D over a lifetime. Although symptoms appear to decrease over time in a small number of children with ADHD, they are the exception, not the rule. In fact, the majority of

1 . An overview of Childhood and Adolescent ADHD

present in the A D H D group, including anxiety and academic difficulties. We need controlled treat- ment studies for adolescents and adults to deter- mine which treatments in isolation or combination are most efficacious.

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Aman, M. G. (1996). Stimulant drugs in the developmental disabilities revisited. Journal ofDevelopmenta1 and Physical Disabilities, 8 , 347-365.

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Barkley, R. A,, Fischer, M., Edelbrock, C. S., & Smallish, L. (1990). The adolescent outcome of hyperactive children diag- nosedby researchcriteria:I.An 8-yearprospectivefollow-up study. Journal ofthe American Academy of Child and Adoles- cent Psychiatry, 29, 546-557.

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Biederman, J. (1998). New data on ADD and girls. ATTEN- TION, 4, 3840.

Biederman, J., Faraone, S. V., Keenan, K., & Tsuang, M. T. (1991). Evidence of familial association between attention

individuals with A D H D in early childhood con- tinue to demonstrate the disorder into adolescence (70-80%) and continue to be symptomatic into adulthood (60%; Ingram et al., 1999). Further- more, each developmental stage presents its unique challenges and life events that are intensified or complicated by A D H D (Teeter, 1998). Thus, a clinical perspective that considers treatment within a developmental framework is imperative.

Second, clinicians would be wise to look for and foster resiliency factors, including special talents, interests, and experiences, to help mitigate the negative impact of ADHD on adults.

Third, it is unclear whether multimodal treat- ment (with or without stimulant medication treat- ment) will prove to be most efficaciousfor adults. In a two-year multimodal treatment study with children, Abikoff and Hechtman (1996) found medication to be as powerful as combined treat- ments (e.g., social skills, parenting skills, tutoring, study skills, and medication). The addition of other treatments did not significantly improve outcome, nor were they more powerful than medication alone. However, as Ingram et al. (1999, p. 249) suggest: “The continuation of treatment may be crucial in influencing positive outcome,” particu- larly stimulant medication. Results of the National Institutes of Mental Health (NIMH) multisite study for children (MTA Cooperative Group,

1999) did find that medication and strong behav- ioral interventions (parent management and a school behavior management system) were effec- tive for treating ADHD for up to 14months. Chil- dren who received medication alone (under the careful supervision of a physician) or a combin- ation of medication with behavioral interventions had reduced symptoms compared to a group re- ceiving behavioral treatments or typical treatments found in the community. It is important to note that in the MTA study, children received careful medication monitoring, which is not typical for community-based interventions. Combined medi- cation and behavioral interventions were very im- portant for reducing other problems that were

Anne Teeter Ellison

deficit hyperactivity disorder and major affective disorder.

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Continuity of ADHD in Adulthood: Hypothesis and Theory Meet Reality

INTRODUCTION

In their discussion of ADHD, Weiss and Hecht- man (1993) suggest that understanding the con- tinuity of childhood conditions into adulthood is far from simple. The traditional, dichotomous view that childhood conditions are either outgrown or continue to manifest in adulthood in a similar way as in childhood (e.g., intellectual handicap) must be countered by a number of other possibilities. For example, symptoms of a particular condition may persist into adulthood, but changes in adult expect- ations and lifestyle, as well as the capacity of human beings to develop compensatory strategies, minimize negative impact or, for that matter, even the visibility a condition may have during the adult years. Children with significant large motor delays, for example, often struggle during their childhood years on the playground and in physical education classes. The impact of delayed large motor skills in combination with ADHD has also been suggested as far reaching (Hellgren, Gillberg, & Gillberg, 1994; Rasmussen & Gillberg, 1999). Yet in adults the avoidance of athletic activities may be the only residual effect.

Clinician’sGuideto Adult ADHD:
AssessmentandIntervention
ISBN0-12-287049-2 25

There are also a number of other outcomes for childhood conditions. A condition could in part remit, but the residual symptoms could cause daily functional impairment, or a condition could pre- dispose an adult to certain other kinds of problems. Gradually, over the last 25 years, all of these hy- potheses, including acceptance of the continuity of ADHD as an impairing condition throughout the life span, have been considered and examined, and they are now better understood.

The existence of A D H D as a clinically impairing condition is irrefutable (Goldstein & Goldstein, 1998; Barkley, 1997). Though the etiology of the condition and precise symptom profile remain de- batable concepts, presenting symptoms and impair- ing consequences are easily observed and measured. In light of current theories portraying ADHD as a condition of impaired development, it should not be a great philosophical or academic leap to accept the condition as presenting throughout the life span (Goldstein & Goldstein, 1998; Goldstein, 1999; Barkley, 1997, 1998). Yet scientific method requires more than just hypotheses and theory before belief can confidently be described as fact. Though thousands of peer-reviewed studies dealing

Sam Goldstein. Ph.D.

with ADHD in childhood have been published, the literature still contains fewer than 100 peer- reviewed articles dealing with adult ADHD. The number of studies has been increasing significantly year by year, including the ongoing, reported results from a number of longitudinal studies following children with A D H D into their adult years. Yet, as with any emerging condition, each published study holds the promise of new data, insight, and perhaps a new path to follow with regard to ADHD in the adult years. Time will determine which paths lead somewhere and which are dead ends.

As discussed in the Preface, for now the field of adult ADHD is driven more by trade texts and lay publications than by the availability of scientific literature to guide clinical practice. Even in clinical practice and research, the misunderstanding of the developmental nature of the diagnosis, particularly the fact that a set of childhood-derived symptoms is currently applied to adults, causes misunderstand- ing and misinformation. For example, in 1996 Hill and Schoener applied the categorical criteria of the DMS-IIIR by reviewing nine prospective studies in which cohorts of children with ADHD were followed up between 4 and 16 years later to deter- mine the number retaining the A D H D diagnosis. The authors subjected the data to nonlinear regres- sion analysis to ascertain the relationship of the condition with chronological age. According to these authors there was an exponential decline over time in the condition. It was suggested that the presence of the condition declined 50% ap- proximately every 5 years. Under this assumption, beginning with a prevalence rate of 4% in child- hood, the authors concluded that the estimated rate of adult A D H D ranged from approximately 0.8% at age 20 to 0% at age 40. The study contained multiple methodological problems, but more im- portantly demonstrated the difficulty of applying childhood criteria to an adult population.

As multiple authors have demonstrated, the number of ADHD symptoms necessary to reach a threshold criterion of a standard deviation and a

Sam Goldstein half between an affected individual and those of

similar age decreases with increasing age (Murphy & Barkley, 1996). These authors compared 172 adults with ADHD to 30 adults without ADHD. All had been referred to an adult ADHD clinic. The authors succinctly demonstrated that the issue is not so much meeting symptom threshold, but the experience of impairment relative to others. Those with A D H D demonstrated a specifically greater prevalence of oppositional, conduct, and substance abuse disorders and greater illegal substance use than did the non-ADHD group. Those with ADHD displayed greater self-reported psychological mal- adjustment, more driving risks, and more frequent changes in employment. Significantly, more indi- viduals with A D H D had experienced a suspension of their driver’s license, had performed poorly, quit, or been fired from their job, and had had a history of poor educational performance as well as more frequent school disciplinary actions against them. Multiple marriages were also more prevalent in the group with ADHD.

In the last 15 years, the biopsychosocial nature of this condition across the life span has become increasingly apparent. Epstein, Conners, Erhardt, et al. (1997) demonstrated that adults with ADHD presented with a longer delay when their attention was misdirected with cues in a reaction-time task measuring hemispheric control. Those with ADHD had difficulty switching when misdirected by cues to the right visual field when the target presented in the left visual field. Gander et al. (1998) administered a battery of neuropsycho- logical tests to 30 adults with ADHD, demonstrat- ing that this population, in comparison to a normal sample, experienced specific problems with the skills necessary to perform test tasks involving visual tracking, auditory attention, and visual con- tinuous performance. Deficits on these tasks sug- gest problems with executive control, likely linked to a dysregulation of the frontal lobes. This pattern of problems, though not always the consensus reached by other researchers, has provided consist- ent evidence of deficits in a variety of tasks sensitive

2. Continuity of ADHD in Adulthood: Hypothesis and Theory Meet Reality 27

to executive function and self-regulation (Jenkins, Cowan, Malloy, et. al, 1998; Holdnack, Noberg, Arnold, Gur, & Gur, 1995).

Readers should consider this chapter a work in progress. Given the nearly exponential growth in interest and peer-reviewed published research deal- ing with adult ADHD and the time span between the completion of the manuscript for this chapter and the publication of the book, approximately 30-50 additional research studies exploring symp- toms, problems, outcome, and, most importantly, treatment of adult ADHD will be published. None- theless, the available research suggests a consistent pattern of emerging trends. This chapter will review these trends with regard to various cognitive, emo- tional, personality, familial, and vocational out- comes for individuals with ADHD. Though some authors have suggested that ADHD may reflect an adapted pattern of skills developed based on an evolutionary model (Hartmann, 1993), the emerg- ing research literature is sobering. N o t a single childhood or adult study exists to suggest that those with A D H D hold any type of advantage over indi- viduals without this condition (Goldstein & Bark- ley, 1998). Further, the increased recognition that ADHD reflects not so much a problem sitting still or paying attention, but rather a problem of self- regulation or self-control, provides a workable hy- pothesis to explain the myriad problems currently identified for adults with histories of ADHD. This plausible explanation for ADHD postulates that rather than an adapted or evolved set of valuable qualities, individuals with A D H D suffer from weaknesses in the development of efficient self- regulatory and executive functions. These cognitive functions fall on a normal curve, much akin to height and weight. Qualities of ADHD appear to place individuals at the lower tail of an adaptive bell curve for these skills.

Current knowledge of adult A D H D is drawn from a variety of sources, including extrapolation from childhood data, studies of comorbid condi- tions and their impact on adult outcome, the family studies, longitudinal or long-term follow-up stud-

ies, and, finally, research into adult-diagnosed ADHD.

OUTCOME OF ADHD IN THE ADULT YEARS

The body of literature attesting to the emotional, cognitive, vocational, academic, substance use, and criminal risks of the condition are growing. It has been estimated from available literature that ap- proximately one-third of adults with A D H D pro- gress satisfactorily into their adult years, another one-third continues to experience some problems, while the final third continues to experience and often develops significant problems (for review see Goldstein, 1995; Hechtman, 2000). By combining a number of outcome studies it is reasonable to conclude that 10-20% of adults with histories of A D H D experience few problems. Sixty percent continue to demonstrate symptoms of ADHD and experience social, academic, and emotional prob- lems to at least a mild to moderate degree, and 10-30% develop antisocial problems in addition to their continued difficulty with ADHD and other comorbid problems (Barkley, 1990; Cantwell & Baker, 1989; Gittelman, Mannuzza, Shenker, & Bonagura, 1985; Herrero, Hechtman, & Weiss, 1994; Satterfield, Hoppe, & Schell, 1982; Weiss & Hechtman, 1993).Interestingly, many of these nega- tive outcomes are linked to the continuity, severity, and persistence of ADHD symptoms. There are very limited data to suggest that females at out- come, when controlling for initial presentation, are at less risk for antisocial problems than are males with ADHD (Herrero et al., 1994). It is fair for clinicians to assume that the absence of significant comorbid disruptive behavioral problems during the childhood years is a good predictor of the absence of the development of antisocial disorders in adulthood. Clinicians should be cautioned, how- ever, that the presence of such problems in child- hood is not necessarily predictive of antisocial outcome for all cases (Werner & Smith 1998). In their follow-up study, Weiss and Hectman (1993)

found only 11% of adults with ADHD to be symp- tom free, with 79% experiencing some type of internalizing problem and 75% experiencing inter- personal problems. In this cohort, 10% had at- tempted suicide and 5% were dead from either suicide or accidental injury.

The continuity of the condition in the form of similar symptoms but different consequences has been well demonstrated by Millstein, Wilens, Bie- derman, and Spencer (1997) in their study of clin- ically referred adults with ADHD. Ninety-eight percent reported difficulty following directions; 92% reported poor sustained attention; 92% had trouble shifting activities; 88% reported being easily distracted; 80% reported losing things; 70% reported fidgeting, interrupting, and speaking out of turn or not listening.

Arthur Robin and colleagues (Robin, Bedway, & Tzelepis, 1998) demonstrated that beyond the risk of clinical comorbidity and the life impair- ment, adults with ADHD appear to be at greater risk to develop dysfunctional personality styles. Fifty percent of individuals with A D H D in their follow-up study, in comparison to 5% of normals, demonstrated a personality style characterized by pessimism, helplessness, and disorganization. In contrast, only 44% of those with ADHD, versus 88% of the normal group, demonstrated a person- ality style consistent with empathy, extroversion, and motivation. In Chapter 3, Russell Barkley and Michael Gordon describe in depth the nature and extent of comorbidity, impairment, and life out- come problems in a longitudinal sample of children followed into adulthood with ADHD. In this chap- ter a brief overview will be provided describing these vulnerabilities and outcomes.

PsychologicaVEmotional

As the number of research studies on adults with ADHD is increasing, the vulnerability of a range of psychiatric problems ADHD correlates with, and may in fact mediate, continues to grow. Mannuzza,

Sam Goldstein Gittleman-Klein, Bessler, Malloy, & LaPadula

(1993), in their longitudinal study, reported that at 24 years of age, those with ADHD demonstrated a higher incidence of antisocial personality dis- order as well as alcohol and substance abuse. Though these authors did not report a higher inci- dence of mood or anxiety disorders in this popula- tion than in controls, others have. For example, Millstein et al. (1997) reported in their adult sample that adults with the combined type of attention deficit hyperactivity disorder demonstrated a 63% incidence of major depression; 23% dysthymia; 17% bipolar disorder, 11% panic disorder; 12% simple phobia; 21% generalized anxiety disorder; and 7% obsessive/compulsivedisorder. Even adults meeting only the inattentive criteria in this study were not immune from fairly similar rates of de- pression, yet they appeared to experience fewer problems with bipolar and anxiety disorders. The true risk of ADHD in contributing to bipolar ill- ness has yet to be defined. In contrast to Millstein et al. (1997), Sachs and Baldassano (2000) found only eight out of a group of 56 adults with bipolar disorder demonstrating a history of ADHD. Those eight were compared with eight without a history of ADHD. The age of onset of the first affective epi- sode was lower for the subjects with bipolar dis- order and ADHD (mean age 12 years) than for those without a history of childhood A D H D (mean age 20 years). Though research on adult females is as sparse as the research on the childhood of females with ADHD, at least one study has dem- onstrated that 70% of females with adult-diag- nosed A D H D experience a history of depression and 62% experience a history of anxiety (Rucklidge & Kaplan, 1997). The incidence of these two con- ditions in the general population reported in this study, though not insignificant (33% depression, 17% anxiety), is still dramatically less than in the clinical group.

The continuity of this condition into adulthood has been well demonstrated. In 1998 Vitelli studied the relationship between childhood conduct dis- order, ADHD, and adult antisocial personality

2. Continuity of ADHD in Adulthood: Hypothesis and Theory Meet Reality 29

disorder in a sample of maximum security inmates. The results confirmed that childhood conduct dis- order and ADHD were significantlyrelated to adult antisocial personality disorders, psychopathy, and impulsivity. The combination of childhood con- duct disorder and ADHD appeared to predict sig- nificantly worse outcome in regard to problems related to adult violence, substance abuse, and in- stitutional misconduct.

The volume of data describing the emotional and psychiatric risks for individuals with histories of ADHD continues to grow, including recently pub- lished studies demonstrating a higher prevalence of anxiety in those with A D H D (Mancini, Van Amer- ingen, Oakman, & Figueiredo, 1999),panic disorder (Lomas & Gartside, 1999), and even seasonal affect- ive disorder (Levitan, Jain, & Katzman, 1999).These later authors found comorbidity of seasonal affec- tive disorder with adult ADHD to be between 10% and 19%. Specifically they found an apparent rela- tionship between female gender, impulsive symp- toms of ADHD, and seasonality.

Symptoms of ADHD have also been found to occur to a higher degree in adults with histories of panic disorder. Fones, Pollack, Susswein, and Otto (2000) reported childhood A D H D features by his- tory occurring in 23.5% of adults with panic dis- order; 9.4% satisfied the full DSM III-R and IV criteria, while 14.1% had subthreshold diagnoses. Two-thirds of the panic patients with A D H D indi- cated persistence of symptoms into adulthood. Though the co-occurrence of ADHD was not re- ported to influence the clinical pattern of panic, the authors suggested that the comorbidity of ADHD with panic disorder may contribute to adverse social outcome.

Cognitive Deficits

Comparison studies of neuropsychological testing in a group of adults with ADHD have reported deficits in executive functioning relating to divided attention, visual scanning, and auditory

attention (Gander et al., 1998), speed of process- ing, and verbal learning (Holdnack et al., 1995). Holdnack et al. demonstrated that adults with ADHD exhibited slow reaction time to target stim- uli. Their psychomotor speed was slower relative to controls. These authors also demonstrated incon- sistent application of a semantic clustering strategy for those with A D H D memory tasks. Individuals with ADHD appeared susceptible to retroactive interference and item recall inconsistency. In sum, adults with ADHD appear to experience a selective pattern of deficits, revealing slow cognitive process- ing and significant problems with list learning. Thus, these patterns of selective cognitive weak- nesses appear continuous between the childhood and adult years (for review of childhood data, see Chapter 1).

Academics

The risk of learning disability as well as of lower achievement secondary to scholastic effort is sup- ported by multiple lines of evidence. Those with ADHD appear to significantly underachieve rela- tive to controls (Gittelman et al., 1985; Weiss & Hechtman, 1986; Barkley & Gordon, 2001). Sig- nificantly fewer children with A D H D graduate from high school than the general population. Sig- nificantly fewer attend college. In the longitudinal studies, only 5% of those with A D H D earned a college degree.

Although the rate of outright learning disability appears to be higher among those with ADHD than in the general population, the lines begin to blur when specific cognitive skills are examined in an effort to explain the academic impairments found in those with ADHD. The most frequently discussed and evaluated deficits relate to those cog- nitive characteristics referred to as executive dys-

function (Denckla, 1994, 1996a, 1996b; Denckla & Reader, 1992). It has been suggested that these impairments over and above intelligence measures and emotional stability indicators best explain why

adults with A D H D are often viewed as experien- cing learning disability. Denckla (2000, p. 307) sug- gests that executive dysfunction is the “zone of overlap between A D H D and learning disabilities.” From Denckla’s perspective these cognitive deficits originate from dysfunction of the frontal lobes or interconnected regions. This impairs a variety of abilities that ultimately affect academic as well as interpersonal relations. As Denckla notes, these problems are endemic but not restricted to popula- tions identified with both learning disability and ADHD, as well as other conditions. Denckla cau- tions, however, that executive dysfunction is “easier to diagnose than ADHD in adults because adult normed neuropsychological tests and measures are available” (2000, p. 298). Although these weak- nesses in some cases are used as markers to explain the underlying deficits of some individuals with ADHD, it is unclear whether they serve as causa- tive explanations, markers, or, for that matter, consequences.

It has also been hypothesized that nonverbal learning disability may overlap with A D H D or the construct of executive dysfunction, because the anterior portion of the right hemisphere is thought to be important in directing self-control and serves an important role in the self-regulatory loop, or the “brain’s braking system” (Castellanos, Giedd, Eckburg, Marsh, Kozuch, et al., 1994;Cas- tellanos, Giedd, Marsh, Hamburger, Vaituzis, et al., 1996).The characteristic description of children with nonverbal learning disability may to some extent overlap with symptoms of ADHD, particu- larly descriptions of being passively inattentive or disorganized. At this time, however, there are no published peer-reviewed studies examining symp- tom presentation, overlap, or clinical course for individuals with either of these conditions or for those who may suffer from both. Interested readers are referred to Semrud-Clikeman and Hynd (1990) for review of research on nonverbal learning dis- ability. Finally, extrapolating from the available child clinical literature, it is reasonable for clin- icians to assume that adults with histories of

Sam Goldstein ADHD are more likely than not to have fallen

behind academically, the result not of skill deficit but of lack of practice for proficiency in those subjects requiring repetitive and sustained effort. Thus, academic areas including nonphonetic spell- ing, execution in written language, math facts, and attention to detail in mathematics may all prove to be areas of weakness in the absence of learning disability for many adults with ADHD.

Vocational Outcome

Adults with ADHD are less likely to graduate from high school then their peers, less likely to attend college, and even less likely to graduate from college. They are more likely to enter the workforce at a lower level than siblings and less likely to be promoted (Barkley, Fischer, Edelbrock, et al., 1990), though reportedly employed at a rate similar to the population’s (Mannuzza, Gittelman- Klein, Konig, & Giampino, 1989; Mannuzza, Klein, Bessler, et al., 1998). They are also likely to experience many more job changes.

The daily lives of adults with A D H D are reported to be fraught with problems that result from faulty self-control, including difficulty with driving. Young adults with histories of attentional problems have been reported to be at greater risk for motor vehicle accident, drinking and driving, and traffic violations. Though to some extent, these outcomes are also contributed to by personal char- acter, gender, and conduct problems as well as driving experience, even after adjusting for these variables, Woodward, Fergusson, and Horwood (2000) found that ADHD during adolescence placed young adults at an increased risk of an injury accident, driving without a license, and other traffic violations. Further, Barkley, DuPaul, and McMurray (in press), in a well-controlled, carefully administered assessment of basic neuro- psychological abilities necessary for driving, driving knowledge, decision making, self-ratings, and ratings by others of driving habits and oper-

2. Continuity of ADHD in Adulthood: Hypothesis and Theory Meet Reality 31

ation of a simulated motor vehicle, confirm that A D H D is associated with a pervasive, multilevel impairment of driving abilities. The group with ADHD, in comparison to a control population, made more errors when rules governing testing performance were reversed. Deficits in multiple areas of driving knowledge and rapid decision making were also evident. During simulated driv- ing, the group with ADHD was more erratic in controlling the vehicle and made many more errors in negotiating simulated driving courses. Both self- ratings and ratings by other indicated that the group with ADHD employed significantly fewer safe driving habits. Further, gender differences and those possibly due to subtypes of ADHD were not found to be significant. Interestingly, Barkley, Guevremont, Anastopoulos, DuPaul, and Shelton (1993) reported that teens with ADHD were also more likely to have driven an automobile illegally prior to the time they became eligible as licensed drivers and were more likely to have their licences suspended or revoked.

Finally, in a prospective follow-up study, Man- nuzza, Klein, Bessler, Malloy, and Hynes (1997) followed males with ADHD demonstrating aver- age intelligence for 17 years in their young adult lives. Those with A D H D obtained lower-ranking occupations. These disadvantages were not ac- counted for by adult mental status. Interestingly, those with ADHD were not unemployed at a rate beyond that of the general population.

Substance Use and Dependence

In 1990, Shekim reported 34% of a population of 56 adults with ADHD demonstrated alcoholism, while 30% demonstrated drug abuse. An inpatient study was completed by Milin, Loh, Chow, and Wilson (1997) with a clinical sample of 36 adults, many of whom met criteria for a diagnosis of ADHD. Those with symptoms of ADHD tended to be more likely to have a history of alcohol combined with drug use disorders. The authors

further reported that symptoms of antisocial per- sonality disorder were far more prevalent in sub- stance abusers with a history of both childhood and adult ADHD than those without this condi- tion. In 1999,Coure, Brady, Saladin, et al. reported histories of substance use in adults in an inpatient setting. In this setting there were significant differ- ences in the percentage of those presenting with A D H D between the substance use disorders groups divided by drug of choice. Of the ADHD subtypes, subjects with combined and inattentive types were significantlymore likely to have ADHD symptoms continue into adulthood than the hyper- activehmpulsive subtype. Those with cocaine use were more likely to have a history of childhood ADHD when compared to those with alcohol or combined substance abuse in groups.

Wilens, Biederman, and Mick (1998) examined the rates of remission and duration of substance abuse in individuals with histories of ADHD. The duration of substance abuse was over 37 months longer in a population of adults with A D H D versus those without ADHD. The median time to remis- sion was more than twice as long in ADHD as in controls (144 versus 60 months). The authors reported a need to replicate their data but sug- gested that ADHD is not only a risk factor for the early initiation and a specific pathway for sub- stance abuse but is also associated with longer duration and a significantly slower remission rate.

Finally, the rate of cigarette smoking in adults with ADHD has also been demonstrated as in- creased relative to the general population (Pomer- leau, Downey, Stelson, & Pomerleau, 1995). In a population of 71 individuals with ADHD with a mean age of nearly 34 years, 42% of the males were current smokers, 13% were exsmokers, and 45% had never smoked. Comparative figures for males in the normal population were 28%, 29%, and 42%, respectively. Thirty-eight percent of females in this group with ADHD were current smokers, 31% were exsmokers, and 31% had never smoked, as compared to 23.5%, 19%, and 57.240,respectively, in the general population. Smokers experienced

greater symptoms of ADHD as children than non- smokers and scored higher on measures of child- hood and adult psychiatric comorbidity. The authors suggested that smokers with ADHD may need treatment with a stimulant and sustained nicotine replacement therapy before they can actu- ally quit smoking.

Antisocial and Criminal Behavior

In Weiss and Hechtman’s (1986) follow-up ADHD population, 25-45% expressed some anti- social behavior, with the lower figure, 25%, refer- ring to those who were qualified for a diagnosis of antisocial personality disorder. As noted, this increased risk has been reported by multiple re- searchers (Robin, Bedway, & Tzelepis, 1998; Bark- ley & Gordon, 2001). Anecdotal reports have long suggested an overrepresentation of ADHD in in- carcerated individuals. In 1999 Curran and Fitzger- ald examined 55 adult male offenders with a mean age of 26 years referred to a prison psychiatric clinic. Only 9% met the DSM-IV criteria for ADHD, leading to a slightly higher-than-expected prevalence among this young adult prison popula- tion. This runs contrary to Eyestone and Howell (1994), who suggest in a population of 100 inmates an incidence of 25% for ADHD. Further, Kapu- chinski (2000) suggests, from his experience as a consulting psychiatrist in a prison setting, that a significant number of individuals present or meet the symptom criteria and history for ADHD.

Symptom Presentation and Definition

In an effort to understand the meaning and course of symptoms of A D H D into adulthood, Murphy and Barkley (1996) collected symptom report data on 720 adults of at least 17 years of age. The adults were obtained by soliciting volun- teers from among individuals entering one of two

Sam Goldstein

sites of the Department of Motor Vehicles in Mas- sachusetts to apply for or renew their driver’s li- cense. These authors constructed two rating scales using the 18 DSM-IV symptom list for ADHD. Each item was rated on a scale of 0 to 3 (rarely or never, sometimes, often, or very often, respec- tively). Inattention and hyperactive-impulsive symptoms were alternated in their numbered pos- itions listed on the scale. One rating scale was completed based upon self-report over the past six months, while on the second, individuals were asked to report their behavior when they were be- tween 5 and 12 years of age. The authors correlated the data, collecting six scores. The first three were summations of the item scores calculated separ- ately for the inattention, the hyperactive-impulsive, and the total ADHD item list. The second three were symptom counts of the number of positively endorsed items calculated separately within the in- attention, hyperactive-impulsive, and total A D H D item list. Creating the symptom counts, the authors considered a symptom as present if the answer given to the item was often or very often (score of 2 or 3). Table 2.1 contains the means and standard deviations for the summary scores for current be- havior by age. Table 2.2 shows the means and standard deviations for the number of symptoms endorsed with a 2 or greater for current behavior at each age group. Both tables report the 93rdpercent- ile cutoff for clinical purposes. Tables 2.3 and 2.4 report the summary scores and symptom counts, respectively, for the retrospective recall of child- hood ratings. These too are provided separately for each age group and gender, for the authors reported finding significant differences between genders in the recall of these behaviors from child- hood.

Murphy, Gordon, and Barkley (2000) extended this work by completing a statistical reanalysis of the original Murphy and Barkley data. In this re- analysis a number of trends were examined. Table 2.5 presents the number of people endorsing each possible number of items at the “at least some- times” level recalled from childhood. Almost 80%

2. Continuity of ADHD in Adulthood: Hypothesis and Theory Meet Reality 33

TABLE 2.1 Means, Standard Deviations (SD), and Deviance Thresholds (+1.5SD) by Age Group for the ADHD Summation Scores for Current Symptoms Collapsed Across Gender

Age

Inattention 17-29 Inattention 30-49 Inattention 50+ Hyper-impulsive 17-29 Hyper-impulsive 30-49 Hyper-impulsive

Total A D H D score Total A D H D score Total ADHD score

Mean SD

6.3 4.7 5.5 4.4 4.5 3.3 8.5 4.7 6.7 4.3 5.1 3.2

14.7 8.7 12.0 7.8 9.5 5.8

+1.5SD cutoff N 13.4 275

11.4 316 9.5 90 15.6 276 13.2 309 9.9 93 27.8 266 23.7 299 18.2 87

50+ 17-29 30-49 50+

Note: From Murphy, K., & Barkley, R. (1996). Updated adult norms for the ADHD Behavior Checklist for adults. The ADHD Report, 4 ( 4 ) , 12-16.

TABLE 2.2 Means, Standard Deviations (SD), and Deviance Thresholds (+1.5SD) by Age Group for Positive Symptom Counts for the ADHD Current Symptoms Collapsed Across Gender

Age

Inattention 17-29 Inattention 30-49 Inattention 50+ Hyper-impulsive 17-29

Mean SD

1.3 1.8 0.9 1.6 0.4 1.o 2.1 2.0 1.5 1.8 0.8 1.3 3.3 3.5 2.3 2.9 1.2 2.0

+1.5 SD cutoff N 4.0 275

3.3 316 1.9 90 5.1 276 4.2 309 2.8 93 8.6 266 6.7 299 4.2 87

H yper-impulsive H yper-impulsive Total ADHD Total ADHD Total ADHD

30-49 50+ 17-29 30-49 50+

Note: From Murphy, K., & Barkley, R. (1996). Updated adult norms for the ADHD Behavior Checklist for adults. The ADHD Report, 4 ( 4 ) , 12-16.

of the sample endorsed 6 or more of the 18 items as having surfaced during their early lives. Nearly 75% of the sample reported they were currently experiencing 6 or more symptoms of ADHD at least sometimes (see Table 2.6). Murphy et al. point out these data powerfully demonstrate the commonality of some ADHD complaints in the general population that may occur independent of possessing the clinical condition. Further, even

when more stringent criteria for symptom fre- quency are applied, 25% endorsed having at least 6 of the 18 symptoms often or very often during childhood (see Table 2.7). Twelve percent endorsed having at least 6 symptoms often or very often in their current lives (see Table 2.8). The authors fur- ther note that almost half of the sample reported that they had failed to give close attention to details or made careless mistakes in their work at least

34 Sam Goldstein

TABLE 2.3 Means, Standard Deviations (SD), and Deviance Thresholds (+1.5SD) by Age Group and Gender for the ADHD Summation Scores for Retrospective Recall of Childhood Symptoms

Scale

Inattention Inattention Inattention
H yper-impulsive
H yper-impulsive
H yper-impulsive Total A D H D score Total A D H D score Total A D H D score

Ages Mean

17-29 11.1 30-49 8.9 50+ 6.1 17-29 10.7 30-49 8.4 50+ 5.6 17-29 21.8 30-49 17.3 50+ 11.6

Males

SD +1.5SD

6.0 20.1 5.6 17.3 4.0 12.1 6.0 19.7 5.6 16.8 3.4 10.7

11.3 38.8 10.4 32.9 6.2 20.9

N Mean 175 8.2

182 7.2 55 3.5 174 9.0 181 6.0 55 3.3 173 17.3 177 13.2 54 6.3

Females
SD +1.5SD N

5.9 17.1 99 6.1 16.4 133 3.1 8.2 38 6.0 18.0 100 5.1 13.7 135 2.7 7.4 39

11.4 34.4 96 10.8 29.4 129 4.5 13.1 37

Note: From Murphy, K., & Barkley, R. (1996). Updated adult norms for the ADHD Behavior Checklist for Adults. The ADHD Report, 4 ( 4 ) , 12-16.

TABLE 2.4 Means, Standard Deviations (SD), and Deviance Thresholds (+1.5SD) by Age Group and Gender for the Positive Symptom Counts for the ADHD Symptom Lists for Retrospective Recall of Childhood Symptoms

Scale

Inattention Inattention Inattention
H yper-impulsive
H yper-impulsive
H yper-impulsive Total A D H D score Total A D H D score Total A D H D score

Ages Mean

17-29 3.3 30-49 2.2 50+ 0.7 17-29 3.1 30-49 2.2 50+ 0.9 17-29 6.4 30-49 4.4 50+ 1.6

Males
SD +1.5SD

2.8 7.5 2.5 6.0 1.4 2.8 2.7 7.2 2.5 6.0 1.5 3.7 5.1 14.1 4.7 11.5 2.2 4.9

N Mean 175 1.9

182 1.7 55 0.2 174 2.5 181 1.4 55 0.4 173 4.5 177 3.1 54 0.5

Females

SD +1.5SD N

2.7 6.0 99 2.6 5.6 133 0.7 1.3 38 2.5 6.3 100 2.0 4.4 135 0.8 1.6 39 4.9 11.9 96 4.3 9.6 129 1.1 2.2 37

Note: From Murphy, K., & Barkley, R. (1996). Updated adult norms for the ADHD Adults. The ADHD Report, 4 ( 4 ) , 12-16.

Behavior Checklist for

sometimes when they were younger. Nearly a quar- ter of the sample reported these symptoms oc- curred often or very often. Over a third reported they frequently had difficulty organizing tasks and activities in childhood. A similar percentage lost things necessary for tasks or activities and reported feeling as if they were driven by a motor. As

Murphy et al. point out, “these data provide powerful testament to the universality of ADHD symptomatology” (p. 4).

Clinicians should be cautioned that if 10-20% of the normal population endorses symptoms of ADHD, the ADHD diagnosis based largely on self-report in the absence of significant impairment

2. Continuity of ADHD in Adulthood: Hypothesis and Theory Meet Reality 35

can lead to substantial overdiagnosis. Further, the risk for misjudgment increases, given that according to these data 25% of the population characterized themselves as having had at least 6 symptoms of ADHD during childhood. These data argue against clinicians’ making diagnoses in the absence of corroborating data. These authors are undertaking a large epidemiologic study, beginning with a large symptom pool of DSM IV descriptors, complaints, and problem consequences of ADHD in an effort to arrive at a statistically sound set of symptom criteria and a threshold of symptoms as well as impairment in making the diagnosis of ADHD in adults. Recently a very similar pattern of data has been reported with a population of nearly 400 college students (Lewandowski et al., 2000). On the basis of their findings and previous

TABLE 2.5 Number of People Endorsing Each Possible Number of Items at the “at least sometimes” Level on a DSM-IV Scale of ADHD Symptoms Recalled from Childhood ( n = 719)

TABLE 2.6 Number of People Endorsing Each Possible Number of Items at the “at least sometimes” Level on a DSM-IV Scale of ADHD Symptoms for Current Functioning ( n = 719)

No. Items endorsed Count Ya

0 19 2.64 1 16 2.23 2 20 2.78 3 18 2.50 4 23 3.20 5 24 3.34 6 34 4.73 7 34 4.73 8 31 4.31 9 46 6.40

10 40 5.56 11 48 6.68 12 56 7.79 13 54 7.51 14 42 5.84 15 45 6.26 16 45 6.26 17 54 7.51 18 70 9.74

Cumulative

2.64 4.87 7.65

10.15 13.35 16.69 21.42 26.15 30.46 36.86 42.42 49.10 56.88 64.40 70.24 76.50 82.75 90.26

100.00

From Murphy, K., Gordon, M., & Barkley, R. (2000). To what extent are ADHD symptoms common?A reanalysis of standardization data from a DSM-IV checklist. The ADHD Report, 8(3), 1-5.

Note: FromMurphy,K.,Gordon,M.,&Barkley,R.(2000).To what extent are ADHD symptoms common?A reanalysis of standardization data from a DSM-IV checklist. The ADHD Report, 8(3), 1-5.

research, these authors suggest that self-report alone of symptoms of ADHD may be a reasonable initial threshold for assessment but should not be used as confirming criterion.

The diagnosis of ADHD in the adult years has been and likely will continue to be a source of contro- versy. Despite the fact that current etiology theor- ies of A D H D are consistent with a lifetime prevalence for this condition, there is still a ten- dency to view this as a childhood problem. Faraone (2000) reviewed five domains of the data addressing the validity of the adult A D H D diagnosis, includ- ing clinical correlates, family history, response to

No. Items endorsed

Count

Ya Cumulative

0 1 2 3 4 5 6 7 8 9

Note:

7 0.97 11 1.53 21 2.92

. 35 4.86

. 36 5.00

42 5.83 38 5.28 59 8.19 52 7.22 55 7.64 59 8.19

. 56 7.78

. 57 7.92

57 7.92 34 4.72 30 4.17 28 3.89 25 3.47 18 2.50

0.97 2.50 5.42

10.28 15.28 21.11 26.39 34.58 41.81 49.44 57.64 65.42 73.33 81.25 85.97 90.14 94.03 97.50

100.00

Sam Goldstein

ditions such as hypo- or hyperthyroidism and even vitamin deficiency can lead to ADHD symptoms as well. The clinician must be sensitive, empathic, and supportive yet also maintain a critical eye and sound clinical judgment. A comprehensive assess- ment involving developmental and medical history, a review of school performance, employment his- tory, past psychiatric history, and social and mari- tal functioning must all be reviewed and considered. Ideally the clinician should rely on sev- eral informants in addition to the patient.

Efforts at arriving at single instrument or bat- tery of instruments to be completed in laboratory settings to diagnosis ADHD have met with little success in childhood or adulthood. There has been increasing recognition that although there are sen- sitive and specific measures identified based upon

TABLE 2.8 Number of People Endorsing Each Possible

Number of Items at the “at least often” Level on a DSM-IV ScaleofADHDSymptomsfor CurrentFunctioning(n=719)

TABLE 2.7 Number of People Endorsing Each Possible

Number of Items at the “at least often” Level on a DSM-IV ScaleofADHDSymptomsRecalledfromChildhood(n=719)

No. Items endorsed Count Ya

0 199 27.68 1 95 13.21 2 68 9.46 3 53 7.37 4 51 7.09 5 37 5.15 6 37 5.15 7 20 2.78 8 21 2.92 9 33 4.59

10 18 2.50 11 10 1.39 12 13 1.81 13 18 2.50 14 11 1.53 15 10 1.39 16 7 0.97 17 12 1.67 18 6 0.83

Cumulative

27.68 40.89 50.35 57.72 64.81 69.96 75.10 77.89 80.81 85.40 87.90 89.29 91.10 93.60 95.13 96.52 97.50 99.17

100.00

Note: FromMurphy,K.,Gordon,M.,&Barkley,R.(2000).To what extent are ADHD symptoms common?A reanalysis of standardization data from a DSM-IV checklist. The ADHD Report, 8(3), 1-5.

treatment, neuropsychological studies, and long- term outcome. For all five the validity and reliabil- ity of this condition in the adult years was con- firmed. However, as Murphy (1993) and Barkley and Murphy (1993) point out, given the limited clinical research in adult ADHD, the process of evaluation must proceed with care, caution, and ethics. Clinicians must not only consider the com- monality of some of these complaints in the general population, but also possess the skills necessary to recognize when these symptoms may be more char- acteristic of other conditions related to affect, sub- stance use, personality, depression, or learning disability. In fact, individuals with almost any psy- chiatric condition and many medical conditions (chronic pain syndrome, traumatic brain injury) endorse many symptoms of ADHD. Medical con-

No.Items endorsed Count Ya

0 220 30.56 1 150 20.83 2 87 12.08 3 66 9.17 4 49 6.81 5 35 4.86 6 28 3.89 7 15 2.08 8 19 2.64 9 16 2.22

10 6 0.83 11 12 1.67 12 6 0.83 13 4 0.56 14 5 0.69 15 1 0.14 16 1 0.14 17

Cumulative

30.56 51.39 63.47 72.64 79.44 84.31 88.19 90.28 92.92 95.14 95.97 97.64 98.47 99.03 99.72 99.86

100.00

Note: From Murphy, K., Gordon, M., & Barkley, R. (2000). To what extentareADHD symptomscommon?A reanalysis of standardization data from a DSM-IV checklist. The ADHD Report, 8(3), 1-5.

2. Continuity of ADHD in Adulthood: Hypothesis and Theory Meet Reality 37

group research, the negative predictive power of these tools, including the continuous performance tests, continues to be poor (Gander et al., 1998; Corbett & Stanczak, 1999; Lovejoy, Ball, et al., 1999; Jenkins et al., 1998; Epstein, Conners, et al., 1998; Epstein, Conners, Erhardt, et al., 1997).

One hundred and forty-three consecutive refer- rals to an adult ADHD speciality clinic were evalu- ated. Thirty-two percent clearly met the diagnostic criteria for ADHD, 32% did not, and another 36% demonstrated ADHD-like features but did not meet full criteria, due to either a lack of childhood history, the presence of complicating psychiatric problems, or a lack of sufficient impairment. Com- pared with the group that did not meet ADHD criteria, those with clear-cut ADHD demonstrated more frequent histories of learning disability in childhood, less effective reading skills, and weaker performance on a continuous performance test. They also demonstrated higher self-reports for symptoms of ADHD on questionnaires. Individ- uals in the uncertain group had a higher rate of current substance abuse than either of the other groups. Clinicians must be cautioned when faced with individuals self-referred for ADHD to recog- nize that the community’s perception of adult ADHD may in fact comprise a better description of general psychiatric conditions than of ADHD specifically (Roy-Byrne et al., 1997).

Catz, Wood, Goldstein, et al. (1998) attempted to determine whether a battery of neuropsychological tests could accurately differentiate those with ADHD from those experiencing major depression or dysthymia. None of the neuropsychological measures could distinguish whether faulty perform- ance classified individuals as ADHD or depressed. Clinicians should be cautious that faulty perform- ance on neuropsychological measures, even those purportedly identified as “tests for ADHD,” may be associated with conditions other than ADHD.

Walker and Shores (2000) evaluated 30 adults with ADHD, 30 mild psychiatric patients, and 30 controls using a continuous performance test as well as measures of attention, executive function, psy-

chomotor speed, and arithmetic. The group with ADHD performed lower than healthy controls on most measures. However, when compared to the psychiatric group, the performance of the group with ADHD was not significantlylower on any of these measures. Thus, neuropsychological measures may be effective in distinguishing normals from those with impairments but may not allow for finer distinctions within the impaired group. This prob- lem may also present in the use of standardized questionnaires (McCann, Scheele, Ward, & Roy- Byrne, 2000). Because assessment is not the primary focus of this text, interested readers are referred to Goldstein and Goldstein (1998), Goldstein (1995), and Barkley (1998). Faulty performance on neuro- psychological measures may not always be within the domain of those sufferingfrom ADHD.

When an evaluation is completed, the clinician must consider the following to make the diagnosis.

1. The symptoms of ADHD have been present since childhood and have been relatively persistent over time.

2. The symptoms should currently exist to a significant degree, causing impairment.

3. This impairment must be observed in multiple life domains, including work, school, social, family, and community.

4. The clinician has carefully considered and ruled either in or out other medical and mental health explanations possibly contributing to symptom presentation and severity and to impairment.

In Chapter 4, Johnoon and Conners provide an overview of an assessment model for ADHD in adulthood.

FACTORS AFFECTING OUTCOME

Ultimately the life course for any human being is affected by varied and multiple factors. An increas- ing body of literature operating from a develop- mental pathways model, however, has increasingly

demonstrated that a number of childhood variables can be used to predict, in a general way, risk of adult problems, as well as identifying insulating or protective factors that reduce risk and increase the chances of a satisfactory transition into adult life (for review see Katz, 1997). As a field, researchers dealing with childhood disruptive disorders, includ- ing ADHD, are slowly beginning to examine these protective factors. For the time being there are limited data available specific to the population of individuals with ADHD in this regard. It is quite likely, however, that those factors that insulate and protect children from other psychiatric conditions, including disruptive disorders, likely affect those with ADHD. Thus, living in an intact household, above the poverty level, with parents who are free of serious psychiatric problems, consistent in their parenting style, and available to their children ap- pear to be among the most powerful variables at predicting good outcome (for review see Goldstein and Goldstein, 1998).

In long-term follow-up studies, at least 70-80% of adolescents with a previous diagnosis of A D H D continued to meet the diagnostic criteria for the condition, with at least 60% reporting impairing symptoms but fewer meeting the diagnostic criteria during the adult years (for review see Ingram, Hechtman, & Morgenstern, 1999). These authors suggest that the decrease in prevalence is in part due to the developmental nature of the diagnostic symptoms. Prognosis for individuals with A D H D in adulthood appears to be influenced by the sever- ity of their symptoms, comorbid conditions, level of intellectual function, family situations such as parental pathology, family adversity, socioeco- nomic status, and treatment history.

There is a broader literature available concern- ing the absence of certain negative factors in pre- dicting outcome. For example, Herrero et al. (1994) demonstrated that females may have less risk simply due to their gender. Subtype differences, specifically children with the inattentive type of ADHD, may also be at reduced risk, for the ab- sence of impulsivity appears to speak to better

Sam Goldstein outcome. In fact, it is hypothesized that problems

with self-control are among the best predictors of future outcome when evaluating young children (for review see Barkley, 1997).

Aggressive behavior in general has been found to predict outcome for children with ADHD. Loney, Whaley-Klahn, Kosier, et al. (1983) associ- ated aggression with negative outcome. Hechtman, Weiss, & Perlman (1984) reported that emotional lability was highly correlated with her aggression and predictive of negative outcome, and Fischer, Barkley, Fletcher, et al. (1993) reported that child- hood defiance was predictive of later arrests.

Additional negative outcome variables for A D H D include parental psychopathology (Offord, Boyle, Racine, et al., 1992),the presence of conduct and oppositional defiant disorders (Barkley, Fis- cher, et al., 1990),learning disability (Moffit, 1990), and lower intellect (Hechtman et al., 1984).

Finally, in a recent study, Wilens, McDermott, Biederman, and Abrantes (1999) evaluated a number of treatment variables, including cognitive therapy and medication, in a chart review to pre- dict course and outcome as the result of treatment. On average the individuals studied were treated for nearly a year in 36 sessions. Treatment was associ- ated with significant improvements in A D H D symptoms as well as with a reduction in anxiety and depressive symptoms. Overall global function- ing was also reported to improve. Nearly 70% of the adults were considered to be much to very much improved in their ADHD symptoms at the end of treatment. Thus, in the adult literature, in contrast to the childhood literature, treatments designed at reducing symptoms of ADHD during the adult years may in fact lead to better long-term outcome. A number of additional studies appear to support the efficacy of these treatments for adult ADHD. Casteaneda, Levy, Hardy, and Trujillo (2000) found stimulant treatment very effective in 18 of 19 patients with a history of ADHD and cocaine abuse. In fact, long-acting stimulants also appeared to improve recovery, with rare relapses reported. Finally, Cox, Merkel, Kovatchev, and

2. Continuity of ADHD in Adulthood: Hypothesis and Theory Meet Reality 39

Seward (2000) report significantly improved driving behavior in adults with ADHD during a medication trial in a study utilizing a driving simu- lator. Beginning with Chapter 6, the contributing authors provide readers with a framework for de- veloping a multimodal treatment program for adults with ADHD.

The hypothesis concerning the continuity of ADHD into the adult years has become reality. Current theory for the etiology of ADHD is con- sistent with a lifetime presentation, reflecting devel- opmental rather than a pathological difference between affected individuals and the general popu- lation. The consequences of living with the burden of a significantly disabling condition reflecting limited self-control results in demonstrated prob- lems for adults with ADHD. The condition serves as a risk factor, limiting their potential for aca- demic and vocational achievement, as well as acting as a catalyst for comorbid psychiatric and life prob- lems. Though much work remains to be done to understand the developmental course, risk, and protective factors involved in the adult outcome of ADHD, clinicians must increasingly turn their research and clinical attention to the care and treat- ment of affected adults.

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Sam Goldstein

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Research on Comorbidity, Adaptive Functioning, and Cognitive Impairments in Adults with ADHD: Implications for aClinical Practice

Russell A. Barkley, Ph.D., Michael Gordon, Ph.D.

In this chapter we discuss three aspects of ADHD in adults that have barely edged their way onto the playing field of clinical research. Indeed, only limited data on comorbidity, adaptive func- tioning, and cognitive impairments have been pub- lished in the scientificliterature. The late arrival on the scene of data about these three issues says much about the relative infancy of research in the adult ADHD arena. For many years, much of the infor- mation available represented little more than ex- trapolations from the voluminous child literature. When studies involving adults finally emerged over the past decade, they focused primarily on estab- lishing the persistence of A D H D symptoms past adolescence and on medication effects. Fortu- nately, while the current store of data may not be abundant, it is ample enough to provide some im- portant clinical clues into these aspects of ADHD.

Although the topic of cognitive impairments involves self-evident aspects of functioning, the other two issues are more ambiguous and deserve

Clinician’sGuideto Adult ADHD:
AssessmentandIntervention
ISBN0-12-287049-2 43

explicit definition. Comorbidity refers to the extent to which other psychiatric disorders co-occur with ADHD beyond that expected by chance alone (the base rates of those other disorders in the general population). Studies of comorbidity therefore address the following question: What other psy- chiatric disorders commonly join with ADHD? Answers to that question have clinical relevance because they directly inform the assessment process and dictate treatment strategies. For example, if comorbidity is a high likelihood among adults identified with ADHD, the clinician’s diagnostic protocol must include strategies for exploring the full range of psychiatric disorders. Without broad- band differential diagnosis, the assessment and en- suing treatment plan might address the least impairing component of the client’s clinical picture.

Aduptive functioning concerns the extent to which an individual can handle routine daily responsibilities that are typical of the average person in the population. It addresses the issue of

impairment in a manner somewhat distinct from the DSM-type strategy of establishing symptom counts. An individual can exhibit the requisite number of A D H D symptoms without necessarily demonstrating significant limitations in the man- agement of routine life tasks. Studies about adap- tive functioning therefore ask the following question: In what aspects of everyday life are indi- viduals with ADHD likely to be impaired com- pared to most people? Answers to this question have import not only for the diagnostic process, but also for the deployment of therapeutic efforts, resources, and even legal protections.

Before addressing these topics in detail, we will first elaborate on several overarching issues.

0 Our review of the literature includes only those findings derived from scientificstudy. While workshop presenters and authors of popular literature about ADHD often describe all manner of features and impairments purportedly associated with the disorder, most of those characterizations are based on speculationandclinicalexperience.Clinical anecdote is a perilous source of information that is vulnerable to error from method artifacts, illusory correlations, and uncontrolled maturational and environmental influences. Referral biases,clinical prejudices, and sampling errors can also grossly distort information derived without the benefit of a scientificmethod. For instance, many experts in the field have voiced the opinion, based on clinicalexperience,thatADHDpromoteshigh levels of creativity. However, the scientific literature in no way supports this conclusion. In fact, available evidenceintimates no link at all between the disorder and verbal or ideational creativity (Murphy, Barkley, & Bush, in press). Theoreticalmodelsalsoimplyanadverse impact of the disorder on certain forms of creativity (goal-directed problem solving or strategy development) (Barkley, 1997a, 1997b).In this instance, as in many others,

Russell A. Barkley and Michael Gordon assertions based on clinical experience fail to

withstand scientificscrutiny. Therefore, while empirical studies certainly have their share of limitations, they nonetheless are a more secure source of information in comparison to clinical speculation.

The reader will notice that the studies we report generally involve two distinct types of clinical samples. The first group consists of individuals who were participants in alongitudinal study of ADHD and, therefore, were identified as symptomatic during childhood. The second brand of studies involves patients who sought treatment during their adult years. While some of these individualsmay have had childhood impairment sufficient to warrant a bona fide

A D H D diagnosis, the subject inclusion criteria for most of these studies offer no such guarantee.Infact,mostofthesestudiesrely entirely (or nearly so) on self-report to document both childhood and current impairment associated with A D H D symptoms. The problem with identifying ADHD based on self-perceptionsisthatthisformofclinicaldata is notoriously unreliable. For example, we recently reported on how common it is for normaladultstoendorseclinicallevelsof ADHD symptoms in regard to childhood history and current functioning (Murphy, Gordon, & Barkley, 2000). Nearly 80% of the sample endorsed 6 or more of the 18DSM-IV items as having surfaced “at least sometimes” duringchildhood.Afull75%reported thatthey werecurrentlyexperiencing6ormoreADHD symptomsatleastsomeofthetime.Whilethese percentages decreased when more stringent severity criteria were applied (that is, the symptoms had to be reported as occurring at least “often”), they stillwerefar abovewhat one wouldexpectgivenprevalenceestimatesforthe disorder. A study by Lewandowski and colleagues (2000) showed similar results for a large sample of college students. These results, in concert with ample evidencethat inattention

3. Researchon Comorbidity,Adaptive Functioning,and Cognitive Impairmentsin Adults with ADHD 45

is a nonspecific symptom associated with most forms ofmentalillness(DSM IV;American Psychiatric Association, 1994),limit confidenceinstudiesforwhichself-reportisthe primary basis for subject inclusion. In the least, one should assume that they aremore likely thanthelongitudinalstudiestoinvolvesubjects who either are relatively well functioning or suffer from other types of psychopathology.

0 Subjects in longitudinal studies will differ from clinic-referred adults in other significant ways, most of which would predispose them toward a greater degree of impairment. In addition to being identified much earlier in life, they were also likely brought for evaluation by others concerned about their adjustment. Most clinic-referred adults with ADHD, in contrast, have not been diagnosed previously in childhood and so may have a somewhat milder variant of the disorder. These differences could significantly affect results in studies of comorbidity, adaptive functioning, and cognitive impairment. Therefore, likely differences between the longitudinal and cross-sectional studies in the kinds of subjects they identified may explain many seemingly contradictory findings.

0 As we indicated earlier, far less is known about ADHD as it appears in adults than about children or adolescents with the disorder. From what literature exists on the subject, the view is emerging that, while ADHD in adults is qualitatively similar to its childhood variant, it differs in important respects. The more advanced physical, cognitive, social, and educational development of adults accounts for some of these differences.The rest are largely associated with the differencesbetween childhood and adult expectations for independence and self-management. In childhood, the major domains of adaptive functioning are focused on self-care,peer relationships, the educational setting, family functioning, and a slowly progressive level of

participation within the larger community (as in clubs, sports, scouts, etc.). By adulthood, these domains have expanded to include occupationalfunctioning,maritalfunctioning, child rearing, sexual activity, driving, financial management, and social contracting (reciprocal altruism or social exchange), among others. Therefore, while the disorder entails consistent types of impairments, their impact will vary across development because of different expectations and demands for adjustment.

0 Some of the inconsistencies between the child and adult literature (or among studies in the adult arena) can be ascribed to ecological factors. Adulthood entails the gradual withdrawal of the social “safety nets” provided by parents, relatives, and formal educational systems alongside the increasing demands for personal accountability. Consequently, the adverse effects of A D H D can be greatly amplified and augmented, depending upon context. With these changes, however, also come opportunities for increasingly varied occupational and social niches that adults can self-select into compared to children. This can mask or attenuate some of the impact the disorder may have produced in earlier settings that were compulsory (e.g., school) but are no longer relevant. Becauseadults are exposed to a much wider diversity of circumstances and life demands, it is easy to understand why studies of adaptive and cognitive functioning produce such varied results.

0 Throughoutthischapterwereviewstudiesthat compare adults referred for A D H D with normal or psychiatric controls. On most dimensions, means for the ADHD group will reflect significantly poorer functioning. However, those lower group means do not necessarily indicate that the variable under study is diagnostic or characteristic of the disorder. For example, we will present studies indicating that individuals with ADHD are

Russell A. Barkley and Michael Gordon

more likely than others to be issued tickets for traffic(driving)violations. However,thisfactor isneither sensitivenor specificto ADHD, since many individuals who receive multiple traffic tickets are not ADHD and not all individuals with ADHD have this driving history. We caution against interpreting differences between groupmeans as diagnostic of the disorder because we too often read statements by clinicians that reflect this practice. For example, case reports frequently include statements such as: “The appropriateness of the ADHD diagnosis for Mr. Smith is demonstrated by his long history of traffic violations and automobile accidents, a pattern typical of individuals with ADHD.” If Mr. SmithhasADHD, itwouldbedocumented by a long and consistent history of global impairment associated with significant impulsive and inattentive behavior. While poor drivingmay be one consequence ofthat history, and is certainly consistent with having the disorder, it is not primary evidence for the diagnosis.

Few of the studies we review include psychiatric controls alongside the ADHD and normal groups. Therefore, differences that emerge between groups of ADHD and normal individuals may be more universal to people with psychiatric disorders than specific to ADHD, per se. Similarly, those studies that compare individuals with ADHD to clinic controls may, in the absence of a normal control group, misinterpret any differences as reflecting the nature of ADHD. In reality, they may say more about the makeup of the individuals with other psychiatric disorders.

DISORDERS COMORBID WITH ADHD IN ADULTS

true comorbidity, the presence or severity of one disorder increases the probability for the presence or severity of other disorders. True comorbidity can arise for many reasons (see Angold, Costello, and Erkanli, 1999 for a complete discussion). Two dis- orders may co-occur more often than by chance alone because both share the same or similar under- lying etiologies. For instance, if ADHD shared some genes with major depression, individuals with one disorder might be more likely to manifest the other. Two disorders may also share identical or similar predisposing factors. Disrupted parenting, family turmoil, repeated family stressors, and social disadvantage, for example, are all predisposing factors to both conduct disorder (CD) and major depression, thereby increasing the probability that the two disorders will co-occur. One disorder may itself directly cause or predispose to the other comorbid disorder. For instance, the poor emotion regulation associated with A D H D may create a greater likelihood of displaying anger and hostility when a person is frustrated by others. Such poor emotion regulation may predispose to or directly cause a greater risk for oppositional defiant dis- order in A D H D children, especially in the context of disrupted parenting. Finally, an often over- looked source of comorbidity is nonrandom mating among adults with particular developmental or psy- chiatric disorders. As a case in point, adults with ADHD may be more likely to mate with adults with learning disorders (Biederman, Newcorn, & Sprich, 1991), thereby creating a higher risk for both dis- orders in any offspring of that mating. These and other factors may help us to understand true comorbidity where it arises in clinical populations.

In clinic-referred samples, comorbidity may be more apparent than real. It can arise as an artifact of referral biases or self-selectionfactors operating in the flow of patients to a particular clinic or prac- titioner. Consider the gatekeeping policies of a large managed care or health maintenance organ- ization (HMO) that refers out to psychiatrists or clinical psychologists only those patients with ser- ious psychiatric problems. These specialists will

The literature on comorbidity makes the distinc- tion between true and artifactual phenomena. In

3. Researchon Comorbidity,Adaptive Functioning,and Cognitive Impairmentsin Adults with ADHD 47

therefore see patients who, simply by consequence of their serious impairment, are highly likely to manifest multiple mental disorders. Any pattern of co-occurrence among psychiatric disorders is more apt to reflect the gatekeeping practices of the HMO, not the footprint of true comorbidity.

Positive or negative self-selection processes can also operate to create pseudo-comorbidity in clin- ical samples. For example, clinicians who accept only cash-paying referrals will more likely develop a clientele of highly educated and affluent adults with ADHD. Studies based on this sample might conclude that adults with ADHD are more intelli- gent, entrepreneurial, creative, and successful than the average person. They might also find far less comorbidity than in studies of patients in public sector mental health settings.

Externalizing Disorders

Children and adolescents diagnosed with ADHD have considerably higher frequencies of comorbid oppositional defiant disorder (ODD) and conduct disorder (CD) than would be due to chance alone (Angold et al., 1999).This appears also to be true for clinic-referred adults having ADHD. Ap- proximately 24-35% of clinic-referred adults diag- nosed with ADHD have ODD, and 17-25% qualify for CD, either currently or over the course of their earlier development (Barkley, Murphy, & Kwasnik,

1996a; Biederman et al., 1993; Murphy & Barkley, 1996b; Spencer, 1997). These figures are well below those reported in studies of ADHD children, par- ticularly studies of hyperactive children, followed to adulthood. In these longitudinal studies, levels of ODD and CD may be double those reported for adults diagnosed with A D H D (Barkley, Fischer, Edelbrock, & Smallish, 1990; Weiss & Hechtman, 1993).Given that CD is frequently a precursor to antisocial personality disorder, it is not surprising that 7-18% of adults diagnosed with ADHD qual- ify for this diagnosis (Biederman et al., 1993; She- kim, Asarnow, Hess, Zaucha, & Wheeler, 1990).

And even among those who do not qualify, many receive higher than normal ratings on those person- ality traits associated with this personality disorder (Tzelepis, Schubiner, & Warbasse, 1995).

Conduct disorder is a strong predictor of sub- stance experimentation and, later, substance de- pendence and abuse disorders. It is therefore hardly surprising to learn that lifetime rates of alcohol dependence or abuse disorders range be- tween 32% and 53% of adults diagnosed with ADHD. Eight to 32% may manifest some other form of substance dependence or abuse (Barkley et al., 1996a; Biederman et al., 1993; Murphy & Barkley, 1996b; Roy-Byrne et al., 1997; Shekim et al., 1990). Tzelepsis et al. (1995) reported that 36% of their 114 adults with ADHD had experienced dependence on or abuse of alcohol, 21% for canna- bis, 11% for cocaine or other stimulants, and 5% for polydrug dependence. At the point of their initial evaluation, 13% met criteria for alcohol de- pendence or abuse within the previous month.

Affective Disorders

Twenty-four to 43% of clinic-referred adults are diagnosed with generalized anxiety disorder and 52% have a history of overanxious disorder (Barkley et al., 1996a; Biederman et al., 1993; Murphy & Barkley, 1996b; Shekim et al., 1990). These figures are distinctly higher than those found in children. This probably reflects referral bias, as has been found to be the case with clinic-referred children having A D H D (see Barkley, 1998). Studies of com- munity samples of children show that ADHD has only a modest (albeit significant) comorbidity with anxiety disorders (odds ratio of about 1.3;Angold et al., 1999). Studies by Murphy and Barkley (1996b) and Roy-Byrne et al. (1997) found no higher degree ofanxietydisordersamongtheiradultswithADHD than occurred in a clinical control group of adults seen at the same clinic who were not diagnosed with ADHD, supporting the referral bias interpretation. Furthermore, prevalence of anxiety disorders

among adults with ADHD who are relatives of clin- ically diagnosed A D H D children is relatively low -just 20% (Biederman et al., 1993). Follow-up studies of hyperactive children into adulthood have also failed to find a higher occurrence of anx- iety disorders (see Barkley, 1998). Still, clinicians specializing in clinic-referred adults having A D H D must prepare themselvesto contend with a relatively high frequency of comorbid anxiety disorders, even if largely the result of referral bias. This may compli- cate treatment planning, for anxiety has been found in some studies to predict poorer responses to stimu- lant medications (DuPaul, Barkley, & Connor,

1998),at least in children.
A D H D shows a significant affiliation with major

depression. Between 16% and 31% of adults with ADHD experience major depression (Barkley et al., 1996a; Biederman et al., 1993; Murphy & Bark- ley, 1996b; Roy-Byrne et al., 1997; Tzelepis et al., 1995). Dysthymia, a milder form of depression, occurs in 19-37% of clinic-referred adults diagnosed with ADHD (Murphy & Barkley, 1996b; Roy- Byrne et al., 1997; Shekim et al., 1990; Tzelepsis et al., 1995). A few studies comparing clinic-referred adults with ADHD seen at the same clinic without ADHD have not found a higher incidenceof depres-

Russell A. Barkley and Michael Gordon sion among the adults with ADHD (Murphy &

Barkley, 1996b; Roy-Byrne et al., 1997). This find- ing,however,maystemfromthefactthatdepression or dysthymia are often present in clinic-referred adults generally, and so would be higher than normal in these particular control groups.

Some clinical reports have found obsessive- compulsive disorder (OCD) to occur in 14%of adults clinically diagnosed with A D H D (Shekim et al., 1990). Others have not found this association. Tze- lepis et al. (1995) reported only 4% of their adults met diagnostic criteria for (OCD). Roy-Byrne et al. (1997) likewise reported a 4.3-6.5% prevalence rate, which was not significantly different from their clin- ical control group. Spencer (1997) recently reported that OCD was somewhat elevated (12%) only among those adults with ADHD having a comorbid tic disorder. The figure for those adults without tics was approximately 2%. OCD therefore does not seem to be differentially associated with ADHD.

A recent study compared 105young adults (age 18-28 years) clinically diagnosed with ADHD to a community control group ( N = 64) similar in age and gender representation (Murphy, Barkley, & Bush, 2000). The pattern of comorbid disorders is shown in Table 3.1. As in other studies, this one

TABLE 3.1 Comorbidity of Clinical Psychiatric Diagnoses (DSM-IV)

Clinical disorders

Oppositional defiant Conduct disorder Major depression Dysthymia

Any anxiety disorder Antisocial personality Alcohol dep./abuse Callnabis dep ./abuse Drug dep./abuse Learning disorders

ADHD YO 36.2

4.8 12.4 21.9

6.7

4.8 35.2 20.0 4.8 41.0

Control YO X2 0.0 29.88

0.0 3.14 3.1 4.21 1.6 13.50 1.6 2.30 0.0 3.14 6.3 18.19 1.6 11.94 0.0 3.14 0.0 35.15

P <

,001 NS

.04 ,001

NS ,001 ,001 NS ,001

Note: ADHD = attentiondeficithyperactivitydisorder;YO= thepercentageofthegroup; x2 = results for the chi-square ana1ysis;p = probability value for the chi-square if significant ( p < .05); NS = not significant; dep./abuse = dependence or abuse disorders.ReprintedwithpermissionfromMurphy, K.R.,Barkley,R.A,,&Bush, T. (2000). Young adults with ADHD: Subtype differences in comorbidity, educational, and clinical history. Submitted for publication.

3. Researchon Comorbidity,Adaptive Functioning,and Cognitive Impairmentsin Adults with ADHD 49

found a higher prevalence of ODD, depression, dysthymia, and substance dependence and abuse, especially for alcohol and marijuana. However, a higher incidence of CD, antisocial personality, and anxiety disorders was not evident in this sample. Such a finding might imply that the comorbidity for those disorders is more likely to occur in clinic- referred adults of older age ranges than that evalu- ated in this study.

To summarize, adults meeting diagnostic cri- teria for A D H D demonstrate significant levels of comorbidity for several other psychiatric disorders. Among these, dysthymia and depression may occur quite often (and possibly anxiety disorders). Op- positional defiant disorder (and perhaps CD) occurs among a substantial minority of adults diag- nosed with ADHD. Most studies also suggest that antisocial personality disorder, and certainly anti- social activities, occur in a small but significant proportion of adults with ADHD. Less, yet still appreciable, is the level of substance dependence and abuse disorders, particularly for alcohol and marijuana, among clinic-referred adults having ADHD. All of this is to say that clinicians seeing adults with ADHD must be prepared to treat these comorbid disorders in conjunction with those treatments that may be needed for ADHD.

COGNITIVE DEFICITS

An increasingly popular research focus concerns performance of adults with ADHD on various neuropsychological tests. Interest has been espe- cially high in measures of executive functioning (EF), because these processes are centerpieces for some current theories (Barkley, 1997a) and models (Brown, 2000) of ADHD. However, researchers initially pursued studies of executive functioning based on the longstanding belief that ADHD inter- feres with prefrontal lobe functioning, which is typically evaluated using E F tasks. Although most of the studies have involved children, some have explored cognitive functioning in adults diag-

nosed with ADHD. As always, the results have shown general consistencies across development, but with some specific and important differences.

Intelligence

Most studies have found that children with ADHD have IQ scores that average about 7-10 points lower than control children (see Barkley, 1998). The same pattern does not hold for studies of adults, most of which have found comparable scores across clinic and control groups (Barkley et al., 1996a; Murphy & Barkley, 1996b). Even when group differences have been detected, (Murphy, Barkley, & Bush, in press), mean scores for both groups are still in the normal range or better. For instance, Biederman et al. (1993) found that their adults diagnosed with ADHD had IQ scores sig- nificantly below their control groups. However, the mean IQ scores for the ADHD group were gener- ally between 107 and 110. These results do not reflect low IQs in the ADHD group as they do the above-average intellectual functioning of the control groups (mean IQ scores were 110-113). Therefore, the conclusion holds that ADHD in adult populations is likely not associated with gen- eral intellectual impairment.

Executive Functions

Neuropsychologists have expanded the term ex- ecutivefunctioningto include a wide range of human abilities: inhibition, working memory, resistance to distraction, strategy development, planning and future-directed behavior, flexibility, problem solv- ing, and organization (Lyon & Krasnegor, 1996).At its essence, executive functioning represents a form ofsocialintelligence(Dimond, 1980)orattentionto and action toward the future (Denckla, 1996).Bark- ley (1997a, 2000) has conceptualized the executive functions as those general classes of self-directed actions that humans employ in self-regulation

toward the future. They are the actions humans take toward themselves, often covert, so as to modify their own behavior and thereby maximize future, over immediate, consequences. These actions in- clude (1) response inhibition, (2) self-directed sensing (especially visual imagery and private audi- tion), or nonverbal working memory, (3) self- directed speech (the internalization of language), or verbal working memory, (4) self-regulation of emotiodmotivation, and (5) self-directed play (flexibility, fluency, and diversity), or reconstitu- tion. Factor analyses of batteries of executive func- tion tests, reviewed by Barkley (1997a), have generally identified factors consistent with this scheme: inhibition, interference control, verbal and nonverbal working memory, emotion regulation, persistence (sustained attention), and fluency.

A literature on the executive functioning of adults with ADHD is beginning to emerge, al- though it lags behind the far more abundant child literature. We review next those studies that ad- dress each major domain of executive functioning as it pertains to ADHD in adults.

Inhibition, Inattention, and Interference Control

Continuous performance tests have been exam- ined for signs of deficits in inhibition and sustained attention in adults with ADHD. Inattention is often reflected in impaired reaction time, reaction time variability, and omission errors, while impulsive- ness may be reflected in commission errors. Studies of children with ADHD often find them to perform continuous performance tasks more poorly than control groups (see Corkum & Siegel, 1993, for a review). Barkley et al. (1996a) found their young adults with ADHD demonstrated more omission (inattention) and commission (impulsiveness) errors on the Conners continuous performance task (CPT) compared to the control group. So did two other studies using this task (Epstein, Conners, Erhardt, March & Swanson, 1997; Seidman, 1997) and studies using other forms of CPTs (Gander et al., 1998).Roy-Byrne et al. (1997) compared adults

Russell A. Barkley and Michael Gordon diagnosed with ADHD (probable ADHD) to a

group having current adult ADHD symptoms with- out persuasive childhood history (possible ADHD) and to a clinical control group using the Conners CPT. In contrast to the preceding studies, they found that those adults having possibleADHD were significantlypoorer on a composite CPT score than the control group, with the probable-ADHD adult group falling between these two groups. Holdnack, Mobers, Arnold, Gur, and Gur (1995) also found poorer CPT performance in adults with ADHD, though in this instance it was on the measure of reaction time only and not omission or commission errors. A study by Kovner et al. (1997) likewise found reaction times on a test measuring the ability to shift response sets in a task to be slower in adults with ADHD(n= 19)compared to a control group (n= 10).Therefore,someevidence,albeitinconsist- ent, suggeststhat adults with ADHD have problems comparable to children with the disorder in the re- alms of response inhibition and sustained attention.

Interferencecontrolrefers to the capacity to pro- tect ongoing executive functioning, such as working memory, from interference by internal or external distracting events. The Stroop Color-Word Test is often used to assess this aspect of inhibition in chil- dren with ADHD; indeed problems with the inter- ference part of the task are among the most reliable findings in children with the disorder (see Barkley, 1997a, for a review). Problems with interference control have been found on Stroop tasks in some studies of adults with A D H D (Lovejoy et al., 1999). Others, however, have not found this to be the case (Corbett & Stanczak, 1999). Differences among the studies in sample sizes, diagnostic criteria for ADHD, and test administration and scoring may account for these discrepancies.

Working Memory

Matochik and colleagues (Matochik, Rumsey, Zametkin, Hamburger, & Cohen, 1996) compared 21 ADHD adults against the norms provided with the neuropsychological tests on a variety of EF

3. Researchon Comorbidity,Adaptive Functioning,and Cognitive Impairmentsin Adults with ADHD 51

measures, particularly those of verbal working memory. They found that performance of mental arithmetic and digit span on the WAIS-R intelli- gence test were significantly below normal, as is often the case in children with ADHD. Other studies (Barkley et al., 1996a; Jenkins et al., 1998; Kovner et al., 1997; Lovejoy et al., 1999) also found adults with ADHD to perform more poorly on digit span, auditory addition, and verbal learning tests. These particular tests have been interpreted as reflecting verbal working memory, all of which might imply difficulties with this EF in adults with ADHD. In contrast, tests of verbal learning and verbal memory have generally not been found to be impaired in adults with ADHD compared to control groups (Holdnack et al., 1995; Kovner et al., 1997).

Flexibility/Fluency

The Wisconsin Card Sort Test (WCST) is fre- quently employed in neuropsychology to evaluate problem solving and flexibility of responding. Results of research on children with ADHD employing this task are often inconsistent and, in the minority of cases where deficits are evident, effect sizes are relatively small (Barkley, 1997a). Performance on this task was found by Barkley et al. (1996a) to be within the normal range in their ADHD young adults. Others also have not found performance on the WCST to discriminate groups of A D H D adults from control groups (Gander et al., 1998;Holdnack et al., 1995;Jenkins et al., 1998; Seidman, 1997). Other tests of flexibil- ity or fluency require subjects to generate as many different verbal responses as possible that fall within certain constraints. For instance, the F-A-S test requires participants to generate as many words that begin with each letter as they can within one minute for each letter. A few studies have found adults with ADHD to be impaired in verbal fluency (Jenkins et al., 1998; Lovejoy et al., 1999). Barkley et al. (1996a) compared a small sample of young adults with ADHD (n= 25) to a control group (n= 23) on measures of verbal fluency and

conceptual fluency (object use) and did not find any differences. This inconsistency in findings could be due to low statistical power in the Barkley et al. study. However, discrepant findings across studies are also found in research on children with ADHD (Barkley, 1997a). More research on verbal fluency and conceptual creativity are in order before a more definitive picture of this cognitive domain of EF can be obtained in adults with ADHD.

Barkley et al. (1996a) found that adults with ADHD performed significantly worse on a nonver- bal working memory task. On this commercially available toy called the Simon Game, the adult must imitate increasingly longer sequences of tone/color key presses. Other measures of nonverbal working memoryhavenotbeenusedwithadultswithADHD, making this yet another area of cognitive function- ing in need of greater research with this disorder.

Response Organization

The Rey-Osterrieth Complex Figure Drawing has been used in neuropsychology to assess both planning and organization. One study used this measure with adults with ADHD and found them to be significantly impaired in accuracy, planning, and neatness as compared to control adults (Schrei- ber, Javorsky, Robinson, & Stern, 1999). As with other areas of EF research in adults with ADHD, efforts to replicate this finding are required before confidence in the results can be assured.

For the most part, neuropsychological studies of adults with A D H D have employed very small sample sizes, often well below the number necessary for adequate statistical power to detect small to mo- derate effect sizes (group differences). As a conse- quence, the failure to find group differenceson some measures for which differences in the child A D H D literature have been found may simply be a result of low power. Clearly, future research on the cognitive deficits associated with ADHD in adults will need to employ more adequate sample sizes before a clearer picture of the cognitive impairments associated with the disorder can be obtained. Nevertheless, those

group differencesthat have been observed have been relatively consistent with those E F deficits found in children and adolescents having ADHD.

For example, Murphy, Barkley, and Bush (2001) recently completed a study of the executive functioning of a large sample of young adults with ADHD (N = 105) in comparison to a community control group ( N = 64). These results are presented in Table 3.2. Many of the E F deficits noted earlier were also found in this study. They essentially rep- licated the findings of earlier studies on EF in ADHD children and extended them to young adults with the disorder, providing evidence of val-

Russell A. Barkley and Michael Gordon idity of this disorder in the adult age range. Prob-

lems in five domains of E F were noted here in the young adults with ADHD, these being response inhibition, poor sustained attention, interference control, and two realms of working memory (verbal and nonverbal).

Sense of Time

A theory of A D H D developed by Barkley (1997a) strongly suggests that the disorder may interfere with the sense of time, particularly the capacity to hold temporal intervals in mind so as

TABLE 3.2

Measure

Interference control
Stroop interference YO Stroop number completed Stroop number of errors

Inattention

CPT variability of RT CPT omission errors WAIS I11 digit symbol

Response inhibition

CPT hit reaction time CPT commission errors

Verbal working memory

WAIS I11 digit span

Nonverbal working memory

Simon: longest sequence

Verbal/ideationalJluency

COWAT F-A-S Test Object usage

Smell identification

Smell test error score Smell test percentile

Unadjusted Group Means and Standard Deviations for the EF and Olfaction Measures

ADHD group
N Mean SD

96 52.2 37.2 96 102.9 13.5 96 1.1 1.6

105 13.6 11.4 105 4.8 7.9 101 56.6 12.0

105 399.5 267.9 105 14.0 8.1

104 16.5 3.9 104 9.8 2.8

104 36.2 13.0 105 16.9 7.2

96 3.2 2.4 96 56.7 28.4

Control group
N Mean SD

ANOVA

F ZJ (ZJ ~ 10) 12.04 ,001 (.008)

Note: ADHD = attention deficit hyperactivity disorder; ANOVA = results for the univariate analyses of variance; F = results of F- test;p = statistical probability for the F-test if significant(<.05); (p = IQ) = statistical probability for the univariate analyses of covariance using IQ as a covariate if significant (<.05); SD = standard deviation; WAIS = Wecshler Adult Intelligence Scale (3rd ed.); CPT = Continuous Performance Test; RT = reaction time; COWAT = Controlled Oral Word Association Test. Reprinted with permission from Murphy, K. R., Barkley, R. A,, & Bush, T. (2001). EFs and olfactory identification in young adults with attention deficit hyperactivity disorder. Neuropsychology, 15, 211-220.

64 74.0 29.4
64 110.2 5.0
64 0.8 1.3 0.29

64 7.5 4.9 64 1.8 3.0 63 64.2 10.9

11.38 ,001 (.013) NS (NS)

16.21 ,001 (.002) 6.28 .13 (NS) 12.73 ,001 (.015)

64 355.1 78.6 0.74

64 10.8 6.8

64 18.0 3.7

64 11.1 3.4

NS (NS) 8.61 ,004 (.007)

5.25 ,023 (NS)

10.12 ,002 (.045)

64 40.5 8.6
64 17.1 5.2 ,003

57 2.2 1.9 57 67.6 26.8

10.07 ,002 (NS) NS (NS)

5.46 ,021 (NS) 5.94 ,016 (NS)

3. Researchon Comorbidity,Adaptive Functioning,and Cognitive Impairmentsin Adults with ADHD 53

to use them to guide behavior. This theory (Bark- ley, 1997a) stipulates that the psychological sense of time arises chiefly out of nonverbal working memory, though it may be further enhanced by self-speech (as in counting to oneself). Working memory (verbal and nonverbal) has been defined as the capacity to hold events actively in mind so as to guide subsequent behavior. This type of memory has been thought to be important for attending to temporal durations that are critical to the timing and timeliness of future directed behavior (Fuster, 1997). Of relevance to ADHD is that working memory and the temporal attention it permits require protection from outside interference by dis- tracting events and so depend on response inhib- ition, or interference control, to provide that protection (Fuster, 1997). Temporal intervals that are longer than one second and are being used to guide behavior appear to be mentally represented in the dorsolateral prefrontal cortical regions and their interconnections to the basal ganglia (Harrington, Haaland, & Hermanowicz, 1998;

“x7
0c c

–c 3

2a
2 4 12 15 45 60

Duration (seconds)

The mean absolute discrepancy scores for each group at each of the sample durations (averaged across two trials). Absolute discrepancy scores reflect the difference between the participant’s time reproduction and the sample duration presented expressed as an absolute value. *p < .05, **p < .01, ***p < ,001. Reprinted with permission from Barkley, R. A,, Murphy, K. R., & Bush, T. (2001). Sense of time in young adults with attention deficit hyperactivity disorder (ADHD). Submitted for publication. Neuropsychology, 15, 351-360.

Figure 3.1

Rao et al., 1997; Rubia et al., 1998). In contrast, response timing that may involve intervals of less than one second may be mediated more by the basal ganglia and cerebellum (Mangels, Ivry, & Shimizu, 1998). As applied to ADHD, the theory predicts that the disorder should be associated with deficits in the sense of time because of the disrup- tion that the problem with interference control (inhibition) produces in using working memory to attend to time.

Barkley, Murphy, and Bush (2001) examined time estimation and reproduction abilities in young adults with ADHD and a control group. The par- ticipants were presented with six different temporal durations. In one version of the task, they simply had to verbally report the duration of the interval. No group differences were evident on that task. But in the time reproduction task, the adults with ADHD made significantly more errors than the control group on several of the longer time dur- ations. The results, graphically depicted in Figure 3.1, replicate several previous studies of children

nI II

In ADHD Control

***

with A D H D (Barkley, 1998). These findings indi- cate that ADHD interferes with the ability to hold a temporal duration in mind so as to then repro- duce the interval. This implies that it is the capacity to use a temporal duration in the guidance of be- havior that is most likely the source of the timing deficits evident in those with ADHD. The sense of time is exceptionally important in adult adaptive functioning, given that time deadlines are ubiqui- tous in adult life. Perhaps these results explain the oft-heard complaint of adults with ADHD that they have a terrible sense of time and are often late for deadlines and other time commitments.

Emotional Self-Regulation

The classification of executive functions noted earlier also implies that difficulties with emotional self-control should be evident in adults with ADHD. This is not an area that has been well investigated. Some suggestive evidence that this deficiency exists in adults with ADHD comes from a study by Ra- mirez and colleagues (1997), who compared college students self-reporting high levels of A D H D symp- toms with those who did not. Measures of state and trait anger, inappropriate methods of expressing anger in social contexts, and interpersonal relations were examined. The high-ADHD-symptom group differed significantly from the control group in having higher levels of state and trait anger, more dysfunctional and inappropriate ways of showing anger, and more labile moods of anxiety/depression. They did not report themselves to express emotions with greater intensity or to be more emotionally responsive to external consequences-a finding rep- licated by Braaten and Rosen (1997) with other col- lege students similarly defined. Yet the parents of participants in the Ramirez et al. study reported their ADHD-like students to have higher levels of anger and poorer methods of expressing it than the parents of control students. This might suggest that youngadultswithADHDmayunderreportthelevel of their own emotional intensity relative to how others see them. In any case, it would be of great

Russell A. Barkley and Michael Gordon interest to determine if these results could be repli-

cated on clinic-referred samples of adults with ADHD.

Sense of Smell

One neuropsychological domain that has been relatively unstudied in children and adults with ADHD is olfactory functioning. Though not an ex- ecutivefunction, olfactory identification ismediated by structures within the prefrontal region of the brain nearby those thought to mediate EF. Specific- ally, olfaction is mediated via the olfactory nerve that courses through the ventral aspects of the pre- frontal cortex to the entorhinal cortex. Patients with damage to the prefrontal lobes often experience a diminution either in their olfactory sensitivity or in their capacity to accurately identify common odors (Eslinger, Damasio, & Van Hoesen, 1982; Hamil- ton, Murphy, & Paulsen, 1999). Substantial neuro- psychological research suggests that the prefrontal cortex may be involved in A D H D (see Barkley, 1997a, for a review; also see Seidman et al., 1996). Neuroimaging studies also have shown the pre- frontal regions to be significantly smaller and less active in children with the disorder (Castellanos et al., 1997;Filipek et al., 1997;Rubia et al., 1998).

These findings imply that ADHD might be asso- ciated with deficits in olfactory identification. The study by Murphy et al. (2001), therefore, included a smell identification test as a means of testing the hypothesis that ADHD may be associated with di- minished smell identification. The results confirmed thehypothesis.Nevertheless,theessenceofscienceis replication and the ruling out of alternative explan- ations for the results. This necessitates that others attempt to replicate these results with adults having ADHDandexcludeanycompetingreasonsforthese findings. It is possible, for example, that adults with ADHDsmoketobaccomorethanthenormalpopu- lation, a difference that could adversely affect smell identification.

If this finding of impaired olfaction in adults with A D H D is replicated, it would raise several ques-

3. Researchon Comorbidity,Adaptive Functioning,and Cognitive Impairmentsin Adults with ADHD 55

tions. Is the problem here one of primary olfactory sensitivity or one ofbeing able to label accurately the sensory information being perceived? And to what extent would treatment with stimulant medication reverse either of these impairments?

Excluding Comorbidity as the Explanation for Deficient Executive Functioning

It is conceivable that the disorders often comor- bid with ADHD have some adverse impact on cognitive functioning and so may contribute to or even explain the findings noted above on EF in adults with ADHD. To address this, efforts were taken in the analyses of the foregoing results of Murphy et al. (2001) to demonstrate that the find- ings were not a function of several comorbid dis- orders commonly seen in ADHD (ODD, CD, depression). This methodological approach lends greater confidence to the attribution of these EF deficits to ADHD.

DOMAINS OF ADAPTIVE FUNCTIONING EXAMINED IN ADULTS WITH ADHD

Self-care

Little or no research exists on the extent to which adults with A D H D adequately care for their physical and mental health. As yet, research- ers have not studied their medical status, physical conditioning, health consciousness, nutrition, hy- giene, and efforts at disease prevention. One aspect of self-care that has been explored involves the extent to which adults manage their use of legal psychoactive substances, such as alcohol. An indi- cation that adults with ADHD may have problems with this area of personal care comes from the earlier findings that these adults are more likely to qualify for substance dependence and abuse dis- orders. Corroborating these clinical diagnoses are the reports of adults with ADHD that they con-

sume more alcoholic drinks per week than do others, that they have gotten drunk more often than others, and that they have been told by others that they drink too much (Barkley, Murphy, DuPaul, & Bush, in press). Similar results are obtained when these adults are questioned about their use of illegal drugs as well. In their study of young adults with ADHD, Murphy, Barkley, and Bush (2001) found that only 11% of the ADHD group felt they were alcoholic (compared to 3% of the control group). However, 29% of the ADHD group had been told by others that they drank too much, compared to just 2% of the control group, and 10% of the ADHD group had been treated for alcohol problems, in comparison to 2% of the con- trol groups. Similar results were obtained for illegal drug use, where 25% of the ADHD group had been told by others that they used drugs excessively (vs. 3% of controls) and 11% had been treated for drug use problems (vs. none of the controls).

It has already been shown that adults with ADHD use alcohol and illegal drugs more than is normal or prudent for health maintenance. If it can also be demonstrated that they smoke tobacco to excess and/or exhibit poorer nutrition, a compel- ling case could be made that the disorder predis- poses these adults to a greater risk of cardiovascular disease and possibly reduced life expectancy.

Educational Functioning

Adults diagnosed with ADHD are likely to have (or have had) problems in academic functioning sometime during their life course. Approximately 16-40% of clinic-referred adults have repeated a grade (Barkley et al., 1996a;Biederman et al., 1993; Murphy & Barkley, 1996b). Up to 43% have also received some form of extra tutoring services in their academic histories to assist them with their schooling (Biederman et al., 1993). Barkley et al. (1996a)found that 28% of their young adult sample had received special educational services, a figure about half that found in hyperactive children

followed to young adulthood, but still higher than normal. Similarly, Roy-Byrne et al. (1997) also found significantly greater frequencies of achieve- ment difficulties in school, grade retentions, and special educational services in adults with ADHD.

The Milwaukee follow-up study of Barkley et al. (1990) has documented substantial difficulties in educational adjustment and attainment in hyper- active children followed to adulthood, as have other follow-up studies (Mannuzza, Gittelman-Klein, Bessler, Malloy, & LaPadula, 1993). For instance, follow-up studies find that 25-35% of these chil- dren are retained in grade at least once prior to completion of schooling. At least 60% are sus- pended from school at least once for disciplinary problems, in comparison to just 18% of a commu- nity control group. The rate of frank school expul- sion is more than 2.5 times that for control children (14% VS. 5%).

The most troubling finding is that more than four times as many ADHD youth fail to complete a high school education compared to normal teens (37% vs. 9%). The economic impact of this high failure rate alone on the life course and potential economic earnings of individuals with A D H D is staggering. Among those youth with A D H D who do complete high school, their class rankings are significantly below normal (lowest 30th percentile vs. 50th percentile), and their grade point average in high school is a D+ to C- (1.7 vs. 2.6) vs. C+ to B- for normal teens. In the Milwaukee study, only 20% of the ADHD group attempted a college pro- gram of any sort, and just 5% (to date) have com- pleted a college degree, compared to 40% or more of normal teens entering college and 35% eventu- ally completing some form of college degree. All of this documents that growing up with ADHD (or hyperactivity) takes a tremendous toll on educa- tional functioning and final educational attain- ment, the long-term occupational and economic impact of which is enormous. Yet this also sup- ports the point made earlier that subjects partici- pating in follow-up studies may have greater

Russell A. Barkley and Michael Gordon

impairment than adults self-referring themselves in adulthood for clinical services, where levels of these various educational outcomes are consider- ably better.

A history of behavior problems and school sus- pensions are also significantly more common in clinic-referred adults with ADHD than in clinical control groups (Murphy & Barkley, 1996b). Yet young adults with ADHD seen in clinics are far more likely to have graduated high school (92%) and to have attended college (68%) than are clinic- referred children with ADHD followed to adult- hood. In the latter group, the high school gradu- ation rate is only about 64% (Barkley, 1998). Some studies indicate that clinic-referred adults with ADHD may have less education than non-ADHD adults seen at the same clinic or than community control adults (Murphy, Barkley, & Bush, 2001; Roy-Byrne et al., 1997), a finding consistent with adult follow-up studies of ADHD children (Man- nuzza et al., 1993). A smaller study, in contrast, did not find this to be the case (Murphy & Bark- ley, 1996b), perhaps because of low statistical power.

Concerning actual academic achievement skills, adults diagnosed with ADHD perform signifi- cantly more poorly on tests of math than control groups (Biederman et al., 1993). Only those adults with ADHD who were relatives of ADHD children were found to be significantly lower on tests of reading in this study. Others have also found clinic-referred adults with A D H D to perform more poorly on reading achievement tests than control groups from the same clinic (Roy-Byrne et al., 1997).Yet the mean scores on both achieve- ment tests in these studies were still within the normal range for these adults with ADHD. Still, these findings are in keeping with studies of chil- dren with ADHD, where they are almost routinely found to be below normal in their academic achievement skills (Barkley, 1998). The prevalence of learning disabilities in adults diagnosed with ADHD is well below that found in ADHD chil- dren, ranging from 0% to 12% in most studies

3. Researchon Comorbidity,Adaptive Functioning,and Cognitive Impairmentsin Adults with ADHD 57

(Barkley, Murphy, and Kwasnik, 1996b; Bieder- man et al., 1993;Matochik et al., 1996).

To summarize, clinically diagnosed adults with A D H D show some of the same types of academic difficulties in their histories as do hyperactive or children with A D H D followed over development, albeit to a milder degree. However, the intellectual levels of clinic-referred adults, as noted earlier, are higher and their likelihood of having academic difficulties is considerably less in most respects than that level seen in children with ADHD followed up to adulthood. This higher level of aca- demic functioning in clinic-referred adults with ADHD makes sense given that they are self-re- ferred to clinics in comparison to children with ADHD. This fact makes it much more likely that these adults have employment, health insurance, a sufficient educational level to be so employed and insured, as well as a sufficient level of intellect and self-awareness to perceive themselves as being in need of assistance for their psychiatric problems. Children with ADHD brought to clinics by their parents are less likely to have these attributes by the time they reach adulthood. They are not as edu- cated, are having considerable problems sustaining employment, are more likely to have had a history of aggression and antisocial activities, and do not seem to be as self-aware of their symptoms as adults having ADHD who are self-referredto clinics(Bark- ley, 1998).

Interpersonal Functioning

No studies have examined the interpersonal re- lationships of clinic-referred adults with ADHD in comparison to control groups. Follow-up studies of hyperactive children in adulthood, however, in- dicate that interpersonal relationships are problem- atic and that these formerly hyperactive children have significantly poorer social skills (Weiss & Hechtman, 1993). Only two studies have examined marital functioning in clinic-referred adults having ADHD, and these have been relatively crude in

their evaluation of this domain. Murphy and Bark- ley (1996b) evaluated 172 adults with the disorder and found them to be more likely to have divorced and remarried than control adults. The adults with ADHD also tended to report less marital satisfac- tion in their current marriages @ < .08). Biederman et al. (1993) also found a separation/divorce rate in adults with ADHD approximately twice that found in a control group. These studies suggest that mari- tal functioning is problematic for a significant subset of adults with ADHD and warrants more detailed examination as to the specific difficulties giving rise to this higher level of separatioddi- vorce.

As for general interpersonal functioning, a study of 105 young adults with ADHD (Murphy, Bark- ley, & Bush, 2000) found them to report signifi- cantly higher scores on the interpersonal sensitivity and hostility dimensions of the Symptom Checklist 90-Revised rating scale than did a sample of com- munity control adults. As noted earlier, some re- search suggests that young adults with high levels of A D H D symptoms may have difficulties with emotional self-regulation, particularly in the man- agement of anger and hostility (Ramirez et al., 1997). Those results were corroborated through parent reports about these same students. Not sur- prisingly then, Ramirez et al. also found these col- lege students with high levels of A D H D symptoms reported more interpersonal problems than a con- trol group. More research is obviously needed on the specificproblems that adults with ADHD may have in emotional self-management and interper- sonal functioning.

Occupational Functioning

Studies of the adult outcomes of hyperactive children (Mannuzza et al., 1993; Weiss & Hecht- man, 1993)indicated significantly greater problems in the workplace, significantly lower occupational status, and a greater probability of being self- employed by their 30s than was evident in control

groups. Less is known about the occupational functioning of clinic-referred adults with ADHD. In the Murphy and Barkley (1996a) study, adults with ADHD reported having been fired more often from their places of employment than had control adults (53% vs. 31%). The adults with ADHD were alsomorelikelytohaveimpulsivelyquitajob(48% vs. 16%) and to report having chronic employment difficulties (77% vs. 57%) than had adults in a clinical control group. The ADHD adults also had changed jobs significantly more often than the control group during the same period of time (6.9% vs. 4.6%). Again, as with the interpersonal status of adults with ADHD, the domain of occu- pational functioning deserves greater research at- tention than it has received to date. Even so, what little is available suggests that problems in the workplace occur more often in adults with the disorder and may be a substantial reason for their seeking clinical services.

Motor Vehicle Operation

One area of adaptive functioning that has begun to receive greater research attention is that of motor vehicle driving in teens and adults with A D H D . Clinic-referred teens with A D H D followed over a 3-to 5-year period have been found to have a significantly higher risk for accidents, citations (especially speeding), and license revocations and suspensions than control teens followed over this same period of time (Barkley, Guevremont, Ana- stopoulos, DuPaul, & Shelton, 1993). They have also been rated by their parents as using less sound driving practices than control adults. More re- cently, these findings were replicated and extended to young adults with ADHD. In their driving of a motor vehicle, adults with ADHD were more likely to have received speeding tickets, to have received more of them, and to have had more motor vehicle accidents (Barkley, Murphy, & Kwasnik, 1996b; Murphy & Barkley, 1996a). These findings have been replicated in several other studies (Cox, Mer-

Russell A. Barkley and Michael Gordon

kel, Kovatchev, & Seward, 2000; Nada-Raja et al., 1997; Woodward, Fergusson, & Horwood, 2000). A consistent observation has been that adults with ADHD are more likely to have had their licenses suspended or revoked than those in the control groups (24-32% vs. 4%).

A more thorough study of driving risks and behavior was undertaken by Barkley et al., (1996b). They found that young adults with ADHD were more likely to have been involved in crashes that resulted in bodily injuries. They also were rated by themselves and by others as demonstrating signifi- cantly less sound driving practices during driving than the control group. The official driving records of these participants corroborated many of these findings. Adults with ADHD had more driving violations on their official records, including speeding tickets, were indeed more likely to have had their licenses suspended or revoked (48% vs. 9”/0), and to experience such suspensions more often (mean of 1.5 vs. 0.1 episodes). The problems with driving in these young adults could not be attributed to poor driving knowledge, because no differences between the groups were found on an extensive assessment of such knowledge. However, these young adults, when tested on a computer driving simulator, displayed more erratic steering of the vehicle and had more scrapes and crashes while operating this simulated vehicle than did sub- jects in the control group.

The most thorough assessment of driving per- formance to date comes from a recently completed study by Barkley, Murphy, DuPaul, and Bush (in press). This project evaluated multiple levels of driving performance and adverse outcomes in a large sample ( N = 105) of young adults with ADHD in comparison to a community control group. These levels included basic cognitive func- tions necessary for driving, driving knowledge and rapid decision making, driving performance (on a simulator), actual driving behavior (self- and other ratings), and history of adverse driving events (self- and DMV reports). Findings similar to those presented earlier concerning adverse outcomes

3. Researchon Comorbidity,Adaptive Functioning,and Cognitive Impairmentsin Adults with ADHD 59

(accidents, citations, speeding, etc.) were obtained in this study. These are set forth in Tables 3.3 and 3.4. Furthermore, this study showed that the young adults with ADHD had difficulties in basic cogni- tive abilities that are a prerequisite for safe driving (motor coordination, reaction time, motor inhib- ition, sustained attention). In their decision making during high-risk driving situations, the ADHD group also demonstrated significantly poorer per- formances, evaluated using a videotaped test of multiple high-risk driving scenarios.

Unlikemany other domains of adaptive function- ing, there is sufficient research available now to un- equivocally indicate that ADHD poses substantial driving risks in young adults. These adults are im- paired across multiple levels of driving performance

relative to control adults. Important now is to inves- tigate the degree to which medications, and other treatment approaches, may be able to reduce these significant problems with driving performance.

Sexual Behavior

We were unable to identify research that exam- ined the sexual functioning of clinic-referred adults with ADHD. Fortunately, some follow-up studies of hyperactive children in adulthood have evalu- ated aspects of sexual activity. In the Canadian longitudinal study (Weiss & Hechtman, 1993), sexual adjustment problems were reported by as many as 20% of the ADHD group in adulthood

TABLE 3.3 Negative Driving Outcomes (Categorical Answers) from the Driving History InterviewandtheOfficial DMVDrivingRecord

Measure

Self-reported history:

Drove illegally before licensed to do so Ever ticketed for traffic violations
Ever had parking ticket
License suspended or revoked

Had a vehicular crash as driver
Ever received a speeding ticket
Ever ticketed for reckless driving Ever ticketed for driving while drunk

Official DMV record

Ever ticketed for traffic violations Licensed suspended or revoked
Had a vehicular crash as driver
Ever received a speeding ticket
Ever ticketed for reckless driving Ever ticketed for driving while drunk

%Yes x2 P 40.6 8.63 ,003

68.8 5.27 ,021 39.1 1.18 NS 4.7 9.05 ,002 67.2 0.51 NS

64.1 4.57 ,032 0.0 6.48 ,010 0.0 3.14 NS

60.9 7.29 ,007 20.3 4.25 ,039 29.7 2.17 NS 50.0 3.13 NS

0.0 1.23 NS 1.6 1.73 NS

ADHD group N %Yes

105 63.8 105 83.8 105 47.6 105 21.9 105 72.4 105 79.0 105 9.5 105 4.8

105 80.0 105 35.2 105 41.0 105 63.8 105 1.9 105 5.7

Control group

Note: ADHD = attention deficit hyperactivity disorder; N = total sample size per group used in the analysis; % Yes = percentage of each group responding affirmatively to this question; x2= results of the chi-square;p = probability value for the chi-square if significant(p 5.05); DMV = Department of Motor Vehicles. Reprinted with permission from Barkley, R. A,, Murphy, K. R., DuPaul, G., & Bush, T. (in press). Driving knowledge, competence, and related cognitive abilities in teens and young adults with attention deficit hyperactivity disorder. Journal of the International NeuropsychologicalSociety.

60 Russell A. Barkley and Michael Gordon TABLE 3.4 Group Means and Standard Deviations for the Dimensional Scores from the Driving History Interview,

Measure

Self-reported history:

Total tickets for traffic violations License suspensions or revocations Vehicular crashes as driver
If so, at faults in vehicular crashes Damage caused in 1st crash ($) Speeding ticket

Tickets for reckless driving Tickets for driving while drunk Parking tickets

Official DMV records:

Tickets for traffic violations License suspensions or revocations Vehicular crashes as driver Speeding ticket
Tickets for reckless driving Tickets for driving while drunk

Driver performance scale:

Self-ratings of performance Other ratings of performance

105

105 96

11.7 20.6 0.5 1.26 1.9 2.4 1.3 1.2

3055.3 7095.8 3.9 5.2 0.2 0.6 0.7 0.3 6.3 16.8

5.1 8.4 1.1 2.2 0.6 0.8 1.6 2.0 0.1 0.2 0.1 0.4

50.5 5.6 48.7 6.7

44 4.8 64 0.1 64 1.2 43 0.9 64 1119.1 44 2.4 44 0.0 44 0.0 44 1.8

63 2.1 63 0.3 63 0.4 63 1.0 63 0.0 63 0.1

63 55.2 63 53.0

3.2 3.07 .21 3.57 1.1 2.55 0.8 2.43 1983.8 2.63 1.5 2.55 0.0 2.75 0.0 2.16 2.3 2.46

2.4 3.45
0.7 3.34
0.7 1.33
1.2 2.46 ,015 0.0 1.35 NS 0.1 1.28 NS

3.7 -6.51 .OOIU 5.3 -4.47 .OOIU

Official DMV Driving Record, and Driving Performance Rating Scales

ADHD group Control group
N Mean SD N Mean SD t P<

Note: ADHD = attention deficit hyperactivity disorder; all results reported are for t-tests except for five measures, the analyses of which employed analysis of covariance. T = Results for the t-test; p = statistical probability for the t-test if significant (<.05); SD = standard deviation; DMV = Department of Motor Vehicles. %dicates that this group difference remained significant after statistically controlling for a group difference in IQ score. Reprinted with permission from Barkley, R. A,, Murphy, K. R., DuPaul, G., & Bush, T. (in press). Driving knowledge, competnece, and related cognitive abilities in teens and young adults with attention deficit hyperactivity disorder. Journal ofthe International NeuropsychologicalSociety.

(versus 2.4% for the control group). However, the authors did not specify the nature of these adjust- ment problems. In the ongoing Milwaukee follow- up study, participants were questioned in late ado- lescence and early adulthood (mean age 20 years) about their sexual activities. Preliminary results indicated that the hyperactive group began having sexual intercourse at an earlier age than the control group (15 vs. 16 years.) and had more sexual part- ners in their lives (19 vs. 7). The hyperactive young adults were less likely to use contraception. Not surprisingly, these young adults were more likely to have conceived a teenage pregnancy (38% vs. 4%), and were more likely to have contracted a

sexually transmitted disease (17% vs. 4%). While many more in the hyperactive group had been tested for AIDS/HIV (54% vs. 21%), none had tested positive. Compared to the control partici- pants, the hyperactive subjects in the Milwaukee study were no more likely to experience sexual dysfunction (impotence, painful intercourse, fail- ures to achieve orgasm, etc.).

These findings indicate a relatively high-risk sexual lifestyle among the formerly hyperactive children on reaching late adolescence and young adulthood. Given that the pattern of findings from follow-up studies in other domains of functioning have largely been replicated in clinic-referred

.003a .OOIU .012a .017a .O1oa ,012 .007a ,033 .016a

.OOIU .OOIU NS

3. Researchon Comorbidity,Adaptive Functioning,and Cognitive Impairmentsin Adults with ADHD 61

adults, though to a lesser extent, the findings reported here for sexual activity intimate that simi- lar problems may occur among adults clinically diagnosed with ADHD. If replicated, they would certainly suggest the need for some preventive sexual counseling in the adolescent and young adult years of individuals having ADHD.

Unstudied Domains

As we indicated at the outset of this section, many central aspects of daily functioning have not been studied. These include child rearing, the management of household responsibilities (cook- ing, cleaning, shopping, etc.), time management more generally, and financial management. And certainly far more needs to be done in the domains of marital and interpersonal functioning and sexual behavior, given the strong suggestion in follow-up studies that these domains are likely to be affected by clinical levels of A D H D in adulthood. Efforts should also be made to study the specific impair- ments that may be occurring in employment set- tings for adults with A D H D as well, given the dearth of information available to date on this important domain of adult adaptive performance.

Our clarion call for research in the area of daily adaptive functioning reflects more than our par- ticular need for empirical tidiness or completeness. Hard data concerning the impact of ADHD on managing routine tasks are absolutely central to solid identification and treatment. After all, if A D H D is anything, it is a disorder of routine task management. What characterizes people with ADHD is that they cannot handle the quotidian aspects of their lives as well as most others. Their impairments are therefore evident not just in chal- lenging environments, but when they must cope with the commonplace. Indeed, someone moves from having ADHD-like characteristics to actually warranting a diagnosis when he (or she) fails at everyday life maintenance. If more information were to become available about these domains of

daily adaptive functioning, it would allow the field to develop an understanding of ADHD that went beyond symptoms lists, to a full appreciation for the impact of those symptoms on functioning.

CLINEAL IMPLlCATlONS

Current research on ADHD in adulthood, while admittedly limited, nonetheless has specific impli- cations for clinical management of the disorder. Indeed, data of the sort we have reviewed form some of the key underpinnings for prudent diag- nostic and treatment strategies. Because the general management of ADHD has been extensively cov- ered elsewhere (see Murphy, 1998; Murphy & Gordon, 1998; Wilens, Spencer, & Biederman, 1998), we will not delve fully into that topic here. Instead, we will simply highlight some of the clin- ical issues we feel our research review has raised.

ADHD is associated with global impairment in functioning. The research we have cited paints a picture of ADHD that leaves little doubt about its harmful effects on adjustment. In every major realm of functioning, individuals with this disorder show demonstrable limitations. It is a testament to the disorder’s impact that it affects such a wide swath of human activity at all developmental levels (see Spencer, Biederman, Wilens, & Faraone,

1994). These data therefore cast serious doubt on the skeptic’s view of A D H D as somehow inconse- quential or trivial. The extant scientific literature provides entirely too much evidence of global im- pairment to justify a dismissive attitude toward this problem. In essence, the ability to attend and exert self-control is fundamental to healthy adjustment. When individuals fall at the extreme, abnormal end of the continuum for these traits, they will inevit- ably struggle in most life circumstances as com- pared to other people. The reader should keep in mind, however, that the research also speaks against a romanticized construal of A D H D as somehow advantageous or adaptive. We cannot

find one research study that suggests a benefit associated with having this disorder (see Barkley, 1998, for further discussion). While individuals with ADHD are not irrevocably destined for gross maladjustment, they are a uniquely vulner- able group. In fact, the evidence for global impair- ment is so strong that it brings into serious question the notion that someone can be ADHD just in narrow slices of functioning. For example, some clinicians have told us that otherwise high func- tioning patients met criteria for A D H D because of narrow limitations in circumscribed aspects of test taking or job performance. Judging from the data we have reviewed (especially involving indi- viduals identified during childhood), A D H D is un- likely to make surgical strikes in narrowly focused domains of a person’s adjustment. The far higher probability is that the disorder will launch a general assault on an individual’s coping abilities.

The impairments associated with ADHD extend beyond inattention and impulsiveness. The concept of executive functioning provides a model for understanding the broad impact of ADHD-type symptoms on adjustment. While ADHD individ- uals will inevitably manifest problems of poor self- control and distractibility, they will also demon- strate other, associated neuropsychological deficits that have significant deleterious effects. Among the most important are problems with nonverbal and verbal working memory. In essence, working memory is a form of attention to the future. Virtu- ally all domains of major life activities require planning, forethought, and otherwise remembering what needs doing and when it needs to be done. It is not so much that adults with ADHD do not know what to do. It is that they cannot do what they know when it would have been important to remember to do so. Given that working memory is essential to a sense of time, timing, and timeliness of behavior toward the future, ADHD may be creating a form of time blindness or future myopia. The data on EF also have implications for treat- ment: Teaching skills, conveying information, or

Russell A. Barkley and Michael Gordon

giving insight into the nature of one’s problems would not be a sufficient treatment approach for ADHD. What individuals with ADHD need most are accommodations in the natural settings at key points of performance. The object of treat- ment is therefore to help them show what they know where and when it is most effective for them to do so.

While clinicians should understand the role of executive functioning in ADHD, they should not regard tests of executive functioning as sensitive or specific to the disorder. Major domains of daily adaptive functioning probably reflect the extent of the disorder and its degree of impairment better than will cursory, short-term observations in clin- ical settings or neuropsychological testing. Execu- tive functioning, and especially working memory, involves the cross-temporal organization of beha- vior-the linking together of events, possible re- sponses, and their likely consequences over large gaps in time among these various contingency ar- rangements. Current tests of executive functions are not up to the task of assessing these complex functions. Although the tip of this iceberg (impul- sivity) might be gleaned from psychological testing, the adverse impact of ADHD on executive func- tioning and the cross-temporal organization of be- havior are not so easily evaluated. Even though studies of groups of adults with A D H D may find differences between their means and those of a normal control group, those group differences do not establish those scores as diagnostic. For clinical diagnosis, the critical issue for the E F tests is their positive and negative predictive power. In studies examining the utility of neuropsychological tests for childhood ADHD, the power has generally been found to be too low to justify reliance on them for clinical diagnosis, especially if they are inter- preted independent of real-life, clinical information (see Gordon & Barkley, 1998). In the adult litera- ture, too few sophisticated studies of EF tests are available to even judge their diagnostic utility. Therefore, we suggest that clinicians focus far

3. Researchon Comorbidity,Adaptive Functioning,and Cognitive Impairmentsin Adults with ADHD 63

more on the extent to which the disorder is inter- fering with the management of daily responsibil- ities in major domains of adaptive functioning, since these domains: (a) are likely to reflect the major social purposes of executive functioning; (b) are a large part of the reason the adult with ADHD has sought clinical services; and (c) are critical to even determining whether or not a true disorder is present.

Comorbidity is commonplace and requires atten- tion during assessmentandtreatmentplanning. Per- haps the most clinically meaningful finding of all those we presented in this chapter concerns the extent of comorbidity associated with ADHD. In at least 70% of cases, an individual with ADHD will have at least one other psychiatric disorder. Oppositional defiant disorder, conduct disorder, major depression, antisocial personality, and sub- stance abuse disorders appear more often in adults with ADHD than would be expected from popula- tion prevalence estimates. The implications for man- agement are significant because they establish a compelling rationale for designing a broad-based diagnostic protocol that explores issues beyond those associated with ADHD. If an evaluation focuses only on ADHD-related concerns, the chances are high that the clinician will miss other disorders, some of which may have even greater negative impact on functioning than ADHD. Our suggestion is that clinicians assume a high probabil- ity of comorbidity for any particular patient and plan both diagnosis and treatment accordingly (see Gordon, 1995). A comprehensive clinical pic- ture will ensure that the individual with ADHD receives all the treatments required, not just those indicated for ADHD alone. In fact, some comorbid disorders may adversely influence the responding of these adults to standard A D H D therapies. As previ- ously noted, high levels of anxiety have been found in some studies to be associated with poorer stimu- lant drug responding, at least in children with ADHD. This implies that clinicians seeing adults with A D H D be cognizant of this possibility. Further

consideration of antianxiety or antidepressant medi- cations may be in order for this comorbid subset of adults with ADHD.

For treatment planning, adopt a chronic disability perspective. For most individuals, ADHD will be a chronic, life-long disability that will require far more than brief evaluation and a short-term inter- vention. As with all chronic disabilities, clinicians will have to program for ongoing monitoring and reintervention if they expect to manage symptoms and preclude more serious secondary complications from emerging. A thriving practice specializing in A D H D in adults will quickly find itself filled with repeat clients who may need to be followed and treated periodically for years. The nature of this particular psychiatric beast ensures that clinicians and patients will settle into a long haul of ongoing assessment, monitoring, reconsideration of lifestyle choices and medication strategies, and effective problem solving.

Occupational and educational accommodations are highly likely. The studies we reviewed indicate that ADHD in adults interferes with educational functioning and eventual levels of educational at- tainment. Those older teens and young adults with bona fide ADHD who beat the odds and gain admission to college will inevitably require accom- modations if they hope to manage inherently high demands for attention, persistence, and executive functioning (see Gordon & Keiser, 1999, for a dis- cussion of these accommodations and the docu- mentation that will necessitate). Medication may be of substantial benefit to the adult with ADHD in both college and occupational settings. Many cases, however, will require additional accommo- dations in view of the limited time course during which medications can be used each day and the fact that a sizable minority (20%) may not respond positively to these medications. Clinicians unaccus- tomed to advising clients on these accommodations and related issues must develop a network of pro- fessional colleagues who are more expert at doing

so if they are to provide a more comprehensive treatment package for these young adults.

The same will be true for the management of problems in occupational functioning as well. Young adults may require advice and even occupa- tional assessment to assist them with finding the most appropriate occupation and employment set- ting in view of their ADHD and comorbid disorders or cognitive deficits. Older adults frequently re- quire assistance with personal and work organiza- tion, time management, and office interpersonal skills. Developing a regional network of specialists in occupational counseling or time management and personal/work organization would seem to be advisable for clinicians that frequently evaluate adults with ADHD.

Problems with driving demand clinical interven- tion. Driving is of major importance to most of the general adult population; indeed the capacity to maintain gainful employment may be predicated on this domain of functioning in many regions. It is also an area in which inhibition, resistance to dis- traction, reaction time, motor coordination, and the executive functions are exceptionally important. Deficienciesin these areas, commonly seen in adults with ADHD, can be life threatening to both those adults and to other drivers around them. The avail- able research is more than adequate to demonstrate that ADHD interferes with many different levels of safe motor vehicle operation. The disorder pre- disposes to a significantly greater risk of adverse driving outcomes (accidents, citations, and license suspensions/revocations). Clinicians must review this domain of functioning with their clients having ADHD and, where appropriate, make necessary recommendations for either limiting driving privil- eges, increasing supervision of independent driving, or even placing the adult with ADHD on stimulant medication for the management of their driving risks. Although there is a relative absence of re- search on the effectiveness of stimulants for the management of driving performance problems, a small pilot study has demonstrated improved per-

Russell A. Barkley and Michael Gordon

formance on a driving simulator in adults with A D H D (Daniel Cox, personal communication, February 2000). In view of this, the fact that stimu- lants are well known to improve inhibition, reaction time, motor control, and the potentially life- threatening consequences of not treating the adult driver having ADHD, all argue forcefully that ser- ious consideration be given to providing stimulants during motor vehicle operation.

Health considerations may be an issue. Althou- gh the topic has been little studied, findings to date suggest that adults with ADHD may have more health, lifestyle, and even frank medical difficulties than the normal population. This would be evident simply from knowing that they use alcohol and illicit drugs (and probably tobacco) more often than does the normal population. Given the poor self- regulatory abilities indicated in the disorder, it is not difficult to imagine that these deficiencies could also adversely impact the individual’s nutritional, exercise, hygiene, and other regimens that influence their health status. This entire area of adaptive func- tioning requires far more research before specific recommendations can be proffered on an empirical basis. Meanwhile, clinicians will certainly need to attend to the possibility that the adults seen in their clinical practice with the disorder may be in need of treatment for substance dependence and abuse as partofthetreatmentpackage.Itisfurthersuggested, though, that clinicians be aware of the larger realm of possible health-related difficulties that may arise in adults with ADHD and perhaps inquire about them as part of the initial evaluation.

Marital counseling could be in order. Admit- tedly, much more research needs to be conducted on the nature, degree, and specificdomains of mari- tal difficulties that arise in cohabiting with a partner that has ADHD. For now, all we know is that adults with ADHD are twice as likely to have marital sep- arations or divorces and tend to report being less satisfied in their marriages than adults in various control groups. This is enough to suggest that clin-

3. Researchon Comorbidity,Adaptive Functioning,and Cognitive Impairmentsin Adults with ADHD 65

icians may want to screen for these problems in the initial evaluation and be prepared to provide refer- rals to marital therapists in their geographic region for a significantminority of adults with this disorder.

Counseling on sexual activities and contraception may be advisable. Research is lacking on whether or not problems exist in the sexual practices or con- traceptive use of clinic-referred adults with ADHD. As we indicated, however, longitudinal data raise concern for hyperactive children upon reaching ado- lescence and adulthood. Nearly 40% of these teens and young adults had been involved in a teen preg- nancy-a 10-fold increase in such risk. And four times as many (16%) had already contracted a sexu- ally transmitted disease. At a minimum, such find- ings should serve to encourage clinicians to discuss sexual behavior along with contraception and dis- ease prevention measures with teens (and their parents) and young adults with ADHD.

ADHD Predominantly Inattentive Type has gar- nered scant research attention and therefore remains somewhat of an unknown. The reader may have noticed that we have reviewed few studies relevant to the adaptive functioning, comorbidity, and cog- nitive impairments associated with A D H D Pre- dominantly Inattentive Type. The fact is that, despite the increasing popularity of this diagnosis in adult populations, precious little empirical data are available to draw any conclusions about the key aspects of management. Only the studies noted earlier by Barkley, Murphy, and Bush (2001) and Murphy et al, (2001) made any effort to examine for subtype differences among their adults with ADHD in driving, executive functioning, sense of time, and comorbidity. Surprisingly, few differences were evi- dent, save comorbidity for antisocial outcomes.

These findings are quite inconsistent with the more abundant literature on ADHD subtypes in children. Those results indicate that individuals classified with the Predominantly Inattentive Type of ADHD, compared to subjects with Combined Type, are more likely to show symptoms of day-

dreaming, staring, passivity, hypoactivity, sluggish information processing, and difficulties with focused attention. (Barkley, 1998; Milich, Ballen- tine, & Lynam, 2001). Children with the Inattentive Type have far less comorbidity for ODD and CD and may be more passive in social interactions with peers (unlike children with Combined Type, who are generally more aggressive, intrusive, and hence rejected). Some research suggests that Inattentive ADHD may be less responsive to stimulant medi- cations than the Combined Type, although this finding requires further replication.

This pattern of distinctive attributes for the Pre- dominantly Inattentive Type has led some investi- gators to call for considering this type of ADHD as actually a separate disorder entirely, if more care- fully defined (Barkley, 1998; Milich et al., 2001). Symptoms of daydreaming, sluggish cognitive tempo, lethargy, and hypoactivity would be prom- inent in their differential diagnosis relative to ADHD Combined Type.

Research on the inattentive variant of ADHD is especially difficult to evaluate in adolescents and adults because samples become progressively con- taminated due to two factors. The first relates to the natural life history of the disorder: Some indi- viduals who once qualified for the Combined Type diagnosis fall out of that category and into the Inattentive one because, as is so often the case, they are not as hyperactive as they were during child- hood. Therefore, the ADHD Predominantly In- attentive Type subject pool can become tainted by Combined Type dropouts, i.e., people who are somewhat less physically overactive and impulsive than they once were but still have all the central clinical features and history of the Combined Type subgroup. Failure to distinguish these now-sub- threshold Combined Types from the more distinct- ive Inattentive Types (who have sluggish cognitive tempos and were never clinically impulsive) will result in clinical and research confusion. It there- fore does not surprise us that research to date has failed to detect differences between Inattentive and Combined Type subgroups.

The other factor that cannot help but muddy the diagnostic and empirical waters in this domain concerns failure to rule out other psychiatric dis- orders before settling on an ADHD Predominantly Inattentive designation. While early-appearing, chronic, and pervasive impulsive/hyperactive beha- vior usually falls within the province of ADHD, inattentive behavior is far more nonspecific. Unless the study involves a credible process by which other psychiatric disorders are ruled out, the resulting subject pool will inevitably contain individuals whose inattention stems from anxiety, depression, substance abuse, or schizophrenia or from any number of other psychiatric or learning conditions (see Gordon & Barkley, 1999, for a more complete discussion). Therefore, until more extensive and compelling research emerges about the Inattentive subtype of ADHD in adults, we counsel caution in overinterpreting the research literature and, indeed, in assigning this diagnosis. Further, we recommend that clinicians exploring this diagnosis for any particular client focus on the distinctive symptoms associated with the Inattentive Type ADHD, that is staring, daydreaming, mental fog- giness, sluggish processing of information, social passivity, hypoactivity, and a dearth of impulsive- ness. Other possible psychiatric and educational explanations must also be ruled out.

CONCLUSION

In this chapter we reviewed empirical findings about the psychiatric comorbidity, cognitive def- icits, and impaired domains of adaptive functioning in adults with ADHD. The results, though still rela- tively sparse, depict ADHD as a disorder that cuts a wide swath across the various domains of major life activities in which adults must demonstrate self- sufficiency. The literature highlights difficulties in educational, occupational, interpersonal, and mari- tal functioning as well as specific deficits in motor vehicle operation. Follow-up studies of hyperactive children in adulthood have also indicated heigh-

Russell A. Barkley and Michael Gordon

tened risks for teen pregnancy and sexually trans- mitted disease. All of these findings suggest that managing the responsibilities of daily adult life can bechallenging for adults with ADHD. Some ofthese impairment domains may well stem from the disor- ganization and time blindness associated with defi- cient executive functioning.

We reviewed a host of implications for the clin- ical assessment and management of adults with ADHD that flow logically from the empirical find- ings. However, recommendations based on this literature must remain relatively general, given the absence of research on the more specificor molecu- lar aspects of the functional impairments that exist within each of these domains of major life activ- ities. The exception is motor vehicle operation, which has been fairly thoroughly investigated. Nevertheless, clinicians must be cognizant of those various difficulties likely to be occurring in clinic- referred adults with ADHD so as to consider them in the formulation of effective treatments for the disorder, its comorbidities, and associated adaptive impairments.

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The Assessment Process: Conditions and Comorbidities

Diane E. Johnson, Ph.D., C. Keith Conners, Ph.D.

This chapter focuses on the assessment process for adults who are seeking a diagnosis of attention deficit hyperactivity disorder (ADHD). At the pre- sent time there are no laboratory tests to confirm the diagnosis of ADHD. The diagnosis is based on a compilation of information that includes a devel- opmental/medical/family/schoolhistory and risk assessment, review of diagnostic criteria (symptom presence and impairment assessment), differential diagnosis of common co-occurring disorders, and ratings scales from significant others and parents (American Academy of Child and Adolescent Psychiatry, 1997). The authors of this chapter are both affiliated with the Attention Deficit Disorder Program at the Duke Child and Family Study Center at Duke University Medical Center. The Duke Child and Family Study Center is a subspeci- alty clinic that integrates mental health research and empirically based clinical services to children and their families. The Attention Deficit Disorder Program is involved in research and clinical ser- vices for A D H D across the life span, from early preschool identification and intervention to assess- ment and treatment of ADHD in adults up to the age of 64 years. This chapter stems from our know-

Clinician’sGuideto Adult ADHD: AssessmentandIntervention ISBN0-12-287049-2

ledge of empirically based assessment procedures as well as our experience in assessing hundreds of adults with and without ADHD. This is intended to be a source for clinicians who want to better understand how to identify ADHD in their practice as well as a tool for researchers who continue to struggle with diagnosing adult ADHD.

The chapter contains five sections: (1) an intro- duction to adult ADHD and our riskmodel that sets the stage for discussing assessment issues; (2) a description and discussion of the current A D H D diagnostic criteria as published by the American Psychiatric Association’s Diagnostic and Statistical Manualfor MentalDisorders, Fourth Edition (DSM- IV; American Psychiatric Association, 1994); (3) a description of empirically based practice par- ameters for the assessment of adult A D H D as pub- lished by the American Academy of Child and Adolescent Psychiatry (American Academy of Child and Adolescent Psychiatry, 1997); (4) a description of our clinical procedures within a medical univer- sity setting for making the ADHD diagnosis in adults; and (5) a discussion of how to guard against overdiagnosing ADHD in adults and dealing with issues of comorbidities inherent in this population.

Diane E. Johnson and C. Keith Conners

INTRODUCTIONTO ADHD IN ADULTHOOD: PRESENTATION AND RISKS

Although Wender (1995) very early noted the importance of ADHD in adults, for the most part the notion that ADHD can persist into adulthood is relatively new and remains controversial in the public opinion polls. Most of the research on adult A D H D has occurred within the past decade, in contrast to 50 years of childhood ADHD research. Adult ADHD research has focused on identifica- tion, prevalence rates, comorbidity, and use of medication for treatment. What is striking about research on adult ADHD is the lack of continuity in the identification of the disorder across the vari- ous studies, due in part to changing diagnostic criteria, differing diagnostic criteria within the United States compared to Europe, as well as a lack of consistency in what constitutes adult ADHD (Conners & Erhardt, 1998). In the past decade, there has been a proliferation of self-help books, documentaries, and television program- ming (Waid, Johnson, & Anton, 1997) and an exponential increase in the prescription of psychos- timulants for adults (Sallee, 1995). “These develop- ments have not been without controversy as the validity of the diagnosis of ADHD, particularly in adults, has been questioned” (Waid, Johnson & Anton, 1997, p. 393). Adding to the complexity, for clinician and researcher alike, is the high rate of comorbidity of A D H D with a number of psychi- atric conditions, including learning disabilities, mood and anxiety disorders, conduct/antisocial personality disorders, and substance-related disor- ders (Biederman, Newcorn, & Sprich, 1991; Bieder- man et al., 1993; Milberger, Biederman, Faraone, Murphy, & Tsuang, 1995).

While research has focused on identification, comorbidity, and treatment, the impact of ADHD on adult academic and occupational outcomes and functioningininterpersonal areasislessstudied.Itis believed that the pattern of academic/occupational and interpersonal difficulties associated with ADHD is similar across the life span. ADHD is

now believed to be a chronic, lifetime disorder that exacts a considerable toll on those suffering from it as well as on the families of those who must care for them (National Institute of Health, 1998). Several other chapters in this text describe in more detail the complexities and morbidity of A D H D in adulthood; however, a brief overview will set the stage for dis- cussing issues of assessment. Although as many as 40% of children with ADHD may no longer be symptomatic by young adulthood, several long- term studies have demonstrated that a significant proportion of those with ADHD end up with serious emotional, interpersonal, social, and economiclimi- tations. These include risks of death by misadven- ture, driving accidents, teenage pregnancy, sexually transmitted diseases, alcohol and other substance abuse, and academic underachievement. In add- ition, profound impairment of self-esteem and per- sonal identity are frequent sequelae in adults with a childhood history of A D H D (NIH, 1998). Adults with ADHD, as a group, compared to adults with- out ADHD, tend to be less educated, have more work-related difficulties,more often quit or are laid off from jobs, hold lower-status jobs, have more social skills difficulties, have elevated rates of di- vorce, separation, and marital dissatisfaction, and have higher rates of gambling, depression, and alco- holism (NIH, 1998). These outcome data play an important role in the assessment of ADHD, as we will discuss further in this chapter.

There are a host of complaints and observations in adults with ADHD that must be considered in the assessment process. Adults with A D H D often complain that they have rapid, brief mood shifts or a hot temper (Sallee, 1995; Ward, Wender, & Reimherr, 1993). In fact, hot temper was one of Wender’s cardinal criteria for the diagnosis in adults. Due to a lifetime of failures associated with A D H D , they often present with low self- esteem, feelings of inadequacy, stress intolerance, and feelings of being chronically overwhelmed. They may report an inability to relax, restless sleep, or an excessively active lifestyle. There can be a lifelong history of not living up to their poten-

4. The Assessment Process: Conditions and Comorbidities

plications, early illnesses or injuries, slowed devel- opment, and environmental stress (Hartsough and Lambert, 1985).The actual amount that these risks may contribute to the expression of ADHD is not known; however, an analysis of these risks is im- portant in the assessment process, as we will discuss further. An important therapeutic contribution of a risk assessment is the implicit communication to the patient that attention to modifiable risks (e.g., parenting style, educational opportunity) plays an important role in the expression of the disorder (Brooks & Goldstein, 2001).

CURRENTADHD DIAGNOSTICCRITERIA, THE DSM-IV

Wender and colleagues (Wender, 1995; Ward, Wender, & Reimherr, 1993) were the first to de- velop specific criteria for the diagnosis of A D H D in adults, known as the Utah Criteria. The Utah Criteria (Ward, Wender, & Reimherr, 1993) emphasized that adult ADHD is a continuation of a childhood disorder, with attentional difficulties and consistent motor hyperactivity continuing into adulthood, a consideration of differential diag- noses (excluding ADHD if major psychopath- ology), and the recognition of associated features of marital instability, academic and vocational difficulties, substance abuse, and atypical responses to psychoactive medications, to name a few. Today, the Utah Criteria are rarely, if ever, utilized in the United States as a diagnostic and research tool. They have been replaced, most recently, by the American Psychiatric Association’s (1994) latest version of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; APA, 1994). Before discussing the DSM-IV criteria for ADHD, it is important to note that the European diagnostic criteria, the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10; World Health Organization, 1992) have evolved into cri- teria that are quite similar. Conners and Erhardt

tial, difficulty keeping jobs or sustaining relation- ships, and a disorganized and inefficient approach to school or work (Sallee, 1995). They may report requiring absolute deadlines in order to complete tasks, multitasking difficulties, misjudging how long it takes to do things, failing to plan ahead, or having to do things right away lest they forget. In interview sessions, you may note disorganization in answering open-ended questions, disinhibition, dis- tractibility, or constant purposeless motion of ex- tremities.

How does an adult end up with ADHD, comor- bidity, and/or the complaints and observationsjust noted? Modern conceptions of disease emphasize that diseases are best conceptualized as an accumu- lation of risks (Conners & Erhardt, 1998). There are a host of pathogens that require certain factors in the host before the disease will manifest, as well as protective factors that operate in the host to ward off the disease. While etiology is discussed in detail in another chapter, it is an important assess- ment issue that should be noted briefly. Conners and Erhardt (1998) describe in detail a host of risk factors, both potentially causal as well as protect- ive, that play a role in the expression of ADHD. One of these risk factors is genetics. Although no single marker for genetic transmission has been located, a comprehensive review of the neurobio- logical literature strongly suggests genetic and bio- logical explanation for ADHD (Zametkin, 1989). Metabolic and nutritional factors have been sug- gested since 1929 in childhood ADHD, and al- though comprehensive reviews of the role of nutrients, food additives, and sugar indicate a limited relationship with the etiology of ADHD, there is current evidence suggesting a complex intertwining of nutrition, exposure to environmen- tal toxins such as lead, and other risk factors (Con- ners & Erhardt, 1998). Another suspected risk factor discussed in Conners and Erhardt’s review is temperament, where it has long been suspected that normal variations in temperament can dispose one to problems with ADHD. Other risks include medical risks, such as pregnancy and delivery com-

(1998) provide further discussion of these two in- struments.

The DSM-IV is a categorical diagnostic system, meaning that the result is either inclusion or exclu- sion, the person either has ADHD or does not. Hinshaw (1994) notes that the ultimate aim of any categorical diagnostic scheme is to identify subgroups that are homogeneous with respect to pathogenesis, symptom presentation, family his- tory, course, and treatment response. While a DSM-IV diagnosis is required in order to obtain treatment for ADHD, the assessment procedure should also encompass dimensional measures of ADHD, such as rating scales, which are discussed later in the chapter. This section focuses on the categorical diagnosis of A D H D as specified in the DSM-IV. The diagnostic criteria are presented, along with comments regarding how to determine whether or not a criterion is met. Keep in mind, though, that the DSM-IV criteria create the poten- tial for both overdiagnosis and misclassification.

ADHD is located in the DSM-IV (APA, 1994) under disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. Each disorder has a diagnostic code (a four- or five-digitnumber). The DSM-IV currently classifies three subtypes of ADHD: (314.00) ADHD, Predominantly In- attentive Type, (314.01) ADHD, Predominantly Hyperactive-Impulsive Type, and (314.01) ADHD, Combined Type. ADHD, Predominantly Inatten- tive Type is what was formerly known as Attention Deficit Disorder, or ADD. The DSM-IV also identifies a fourth ADHD diagnostic category, (314.9) ADHD, Not Otherwise Specified (NOS). ADHD, NOS is used for disorders with prominent symptoms of inattention or hyperactivity-impulsiv- itythatdonotmeetfullcriteriaforADHD.Also,for individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, “In Partial Remission” should be specified.

In order to be classified ADHD by DSM-IV, five diagnostic criteria must be met (APA, 1994). These criteria follow, along with comments related to adult ADHD.

Diane E. Johnson and C. Keith Conners

A. At least six of nine symptoms of inattention and/or at least six of nine symptoms of hyperactivity- impulsivity have persistedfor at least 6 months to a degree that is maladaptive and inconsistent with de- velopmental level. The nine inattentive symptoms [with our developmentally appropriate adult exam- ples included in brackets] include the following.

1. Often fails to give close attention to details or makes careless mistakes [e.g., accuracy is sacrificed for speed, fails to check over work, not good with detailed work].

2. Often has difficulty sustaining attention [cannot keep mind of a single activity for long periods, long conversations with friends are difficult to follow, fun activities like watching sports are difficult to track].

3. Oftendoesnotseemtolistenwhenspokento directly [others complain that the mind appearstobeelsewhere,peoplecalltheperson “spacey” or “not there,” people repeat the individual’sname to get his or her attention].

4. Often does not follow through on instructions and fails to finish things [needs deadlines to get things completed, is unable to follow through on multiple commands given at once, jumps from task to task].

5. Often has difficulty organizing tasks and activities [does not plan ahead, depends on others for order, has a poor sense of time, is often late, is inefficient,makes lots of lists that are not used],

6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained attention [procrastinates, delays detailed work like filing taxes].

7. Oftenlosesthings[isabsent-minded,loses keys, wallet, organizers, lists].

8. Often is easily distracted cannot filter out unnecessary noise, has a difficult time refocusing after being interrupted, daydreams].

9. Often is forgetful [forgets to schedule or use organizer, has others help remember, returns

4. The Assessment Process: Conditions and Comorbidities

Wells, and Conners (1995) discuss developmental differences in A D H D symptoms across the life span. In adults, ADHD may present as disorganiza- tion, poor concentration, not finishing things, pro- crastination, impulsivity, affective dyscontrol, anxiety, substance abuse, and antisocial behavior.

Secondly, the DSM-IV is not adjusted for developmental changes in the number of symp- toms. There is some question as to whether or not six or more symptoms must be present in adulthood to accurately diagnose ADHD. Murphy and Bark- ley (1995), in a study of 467 adults with ADHD, found that the number of symptoms needed to ac- curately diagnose ADHD, with a 93% confidence level, declined significantly over time. The authors were able to accurately categorize 30- to 49-year- olds with only four of nine symptoms; for adults 50+ years of age, only three of nine symptoms were required; and interestingly, in 17- to 29-year-olds, only four of nine inattentive and five of nine hyper- active-impulsive behaviors were required. How- ever, the current diagnostic criteria require the six or more symptoms, and if medicolegal or research considerations require a formal diagnosis, one should not deviate from the DSM-IV criteria. Hopefully, future revisions in the DSM will address some of these concerns.

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. This criterion is also contro- versial when diagnosing A D H D in adulthood, for at least two reasons. First, it is very difficult for many adults to document when symptoms first pre- sented and impaired their functioning. Retrospect- ive memory may not be accurate, and there may be no collateral informants to corroborate early child- hood history. Second, because the criterion states that some symptoms were present and impaired functioning before the age of 7 years, it is unclear whether or not the adult has to meet full childhood criteria for ADHD in order to continue to meet criteria in adulthood. In research studies of adult ADHD, it is more common for there to be

home during the day to retrieve forgotten items].

The nine hyperactive-impulsive symptoms in- clude the following.

1. Often fidgets [cannot sit still, bites nails, taps feet and fingers].

2. Often leaves seat [difficulty staying seated through a television program or lecture, likes to do active things].

3. Often runs about or climbs excessively [feels internal restlessness].

4. Often has difficulty playing or engaging in activities quietly [talks during movies, talks loudly in restaurants, has difficulty moderating speech volume].

5. Often is “on the go” [is always moving, is unable to relax].

6. Often talks excessively [takes a long time to get a point across, people complain that they cannot get a word in].

7. Often blurts out answers [says things without thinking, rarely hears the end of others’ sentences, “sticks foot in mouth” frequently].

8. Oftenhasdifficultyawaitingturn[isimpatient in lines and traffic, more so than others].

9. Often interrupts or intrudes on others [“steps on peoples’ toes”, violates others’ space/ boundaries, is called intrusive].

The examples in brackets are taken from the Con- ners Adult ADHD Diagnostic Interview for DSM- IV(CAADID;Conners,Epstein,&Johnson,2001). Criterion A brings up several diagnostic issues related to ADHD in adulthood. First, these inatten- tive and hyperactive-impulsive symptoms represent a set of behaviors that every human exhibits from time to time. Everyone forgets things, interrupts others, or gets distracted (Murphy & Barkley, 2000). These symptoms also present differently across the life span. The DSM-IV criteria do not allow for such symptom variation and, thus, the clinician must be sensitiveto the adult presenta- tion of these childhood-based symptoms. March,

documentation of a childhood diagnosis of ADHD as well as a current diagnosis of ADHD. However, the way the criteria are written, as long as some symptoms were present that impaired functioning before age 7 years, a diagnosis of A D H D may be met. Requiring a specific age of onset for A D H D is controversial and may also be addressed in future revisions of the DSM.

C. Some impairmentfrom the symptoms ispre- sent in two or more settings (e.g., at school or work and at home). It is essential when applying the DSM categorical scheme that impairment be deter- mined. This means that even if the person has six of nine inattentive and/or six of nine hyperactive-im- pulsive behaviors that have persisted for at least 6 months and with an onset prior to the age of 7 years old, they do not count unless the symptoms result in significant life impairment in more than one domain offunctioning. ADHD is not just the presence of inattention or hyperactivity; it is the presence of these symptoms to the point that they are impairing functioning. Impairment is different than symptom presence. For example, avoiding tasks requiring sustained attention is the symptom, the impairment from this avoidance may include not paying bills or taxes on time and being penalized, or, in the work- place, being passed over for a promotion because time lines are not met. For adults, impairment set- tings might include school (college functioning), work (occupational performance), home (conduct- ing daily life activities, marital adjustment, or parenting), or social (friendships, sports, or club activities). Examples of impairment in academic functioning, then, may include receiving lower grades because assignments are not completed and turned in by deadline, chronic lateness or missing classes due to disorganization, or avoiding taking required courses because the subject requires con- centration and attention that the person has diffi- culty maintaining. Unfortunately, the DSM-IV provides no operational guidelines for determining impairment, nor does it provide a complete list of settings.

Diane E. Johnson and C. Keith Conners

D . There must be clear evidence of clinically sig- niJicant impairment in social, academic, or occupa- tional functioning. As already stated with criterion C, the DSM-IV provides no operational guidelines for determining clinically significant im- pairment. What is required here is that one domain of functioning be clinically significantly impaired. An example of this may be that the person has con- tinuously lost jobs or dropped out of school (as opposed to receiving poor work performance reports or lower grades) or fails to maintain friend- ships (as opposed to having difficultieswith relation- ships). Other domains of impairment may include functioning within the home and intrapersonal func- tioning (sense of self-efficacyand self-esteem).Low self-esteemitself is common among many well-func- tioningadults.Butwhenself-esteemisloweredtothe point that there is demoralization, depression, lowered vocational effort, or constant and inhibiting self- criticism, then impairment is present.

E. The symptoms do not occur exclusively during the course of a pervasive developmental dis- order, schizophrenia, or other psychotic disorder and are not better accounted for by another mental dis- order (e.g., mood disorder, anxiety disorder, disas- sociative disorder, or a personality disorder). This criterion is also perhaps the most challenging in assessing the adult with ADHD. Issues of differ- ential diagnosis, comorbidity, and the effects of the natural aging process make this criterion par- ticularly difficult. With regard to comorbidity, the same diagnoses that are common in childhood A D H D are believed to be common in adult ADHD, and the adult with ADHD is more likely than not to have a comorbid psychiatric condition (Biederman, Newcorn, & Sprich, 1991). In cases of adult ADHD, it is believed that depression co-occurs in 15-75% of cases, anxiety in 25% of cases, antisocial personality disorder in 30-50% of cases, substance use in 30-50% of cases, and learn- ing disabilities in anywhere from 10% to 90% of cases (Biederman, Newcorn, & Sprich, 1991). In this regard, the clinician must determine not only

4. The Assessment Process: Conditions and Comorbidities

sessment. These practice parameters also include treatment planning and treatment, but these aspects of the guidelines are beyond the scope of this chap- ter. In general, the practice parameters for an adult A D H D evaluation, as specified by AACAP, requires a complete psychiatric assessment, including: (a) an interview with the patient to obtain a developmental history, psychiatric history and past treatments, pre- sent and past DSM-IV ADHD symptoms, im- pairment history (including the domains of school, work, family, and peers), differential diagnosis of alternate and/or comorbid DSM-IV disorders, an assessment of strengths, talents, and abilities, and mental status examination; (b) standardized rating scales completed by the patient’s parent (where available); (c) medical history; (d) family history; (e)interviewwith significantother or parent, if avail- able; (0physical evaluation (if not completed within the past year); (8) school information; and (h) refer- ral for additional evaluations if indicated (such as psychoeducational, neuropsychological, or voca- tional evaluations).

The practice parameters (AACAP, 1997)provide this additional information for the clinicians. A D H D is often missed in adults, particularly if the disorder was not identified when the patient was a child. As we have witnessed as well, adults often seek evaluation and treatment after the child has been diagnosed and the parent recognizes the symptoms. Adults with undiagnosed ADHD in childhood may have been missed because either some comorbid condition clouded the picture (e.g., a chaotic school or comorbid anxiety) or they were extremely bright or compliant, had consistent discipline at home, an accommodating school team, or interpersonal charm that allowed the child to cope with symptoms of ADHD enough so as to not be impaired. This is particularly true of the ADHD, Predominantly In- attentive Type (AACAP, 1997). Thus, the clinician must be trained in assessingthe adult from a devel- opmental perspective, looking for childhood under- achievement or labeling such as being undisciplined, unmotivated, or “spacey” (AACAP, 1997). Since adults with ADHD may possess limited insight into

if ADHD is present, but also if psychiatric condi- tions co-occur as well.

ThedifferentialdiagnosisofADHDinadulthood is difficult not only due to comorbidity, but due to a host of other conditions that may also include atten- tion or organizational deficits (Waid, Johnson, & Anton, 1997),thus presenting as ADHD but in actu- ality not ADHD (i.e., misclassifying another condi- tion as ADHD). Other such psychiatric conditions may include, but are not limited to, substance intoxi- cation or withdrawal, intermittent explosive disor- der, borderline personality disorder, posttraumatic stressdisorder,mentalretardation,bipolar disorder, Tourette’s disorder, major depression (with agita- tion), and adjustment disorders. Medical conditions could include head injury, hyper-hypothyroidism, multiple sclerosis, epilepsy, stroke, dementia, hep- atic or renal insufficiency, vitamin deficiency states, sensory deficits (such as hearing loss), drug side effects, stroke, and frontal, parietal, or temporal tumors, to name a few (for review see Waid, John- son, & Anton, 1997). In addition to psychiatric or medical conditions, other causes for inattention or organizational deficits may include the normal aging process, environmental stress, and age-appro- priate high activity levels (Waid, Johnson, & Anton,

1997).

PRACTICE PARAMETERS FOR THE ASSESSMENT OF ADULT ADHD

In 1997,the Journal of the American Academy of Child and Adolescent Psychiatry (AACAP) pub- lished practice parameters for the assessment and treatment of children, adolescents, and adults with ADHD. These guidelines may be obtained via the Academy of Child and Adolescent Psychiatry’sWeb site at http://www.aacap.org. These ADHD practice par- ameters are the only ones published for adults to date. These practice parameters were developed by the Work Group on Quality Issues with AACAP and are based on an exhaustive review of the litera- ture, providing empirically based guidelines for as-

their difficulties and may be poor reporters, relying on current information from spouses, significant others, or employers, as well as retrospective reports from parents, is important. School records and past psychiatricreportscanmakeamajorcontributionto the assessment, as can a medical history and recent physical examination. Psychological testing or neuropsychological testing may be indicated but is not necessarily required (AACAP, 1997). This mul- timodal assessment has been advocated and exam- ined in the childhood A D H D literature for several years (Conners & Erhardt, 1998). As Conners and Erhardt note, “The major problem with these multi- level assessments is how to integrate information across informants and domains in such a way that the needs of both diagnosis and treatment formula- tion are served” (p. 505).

The AACAP (1997) practice parameters indi- cate that standardized rating scales may be useful. We find that they are helpful and important tools when used in conjunction with the categorical diag- nostic system of the DSM-IV (APA, 1994).Rating scales provide an alternative method of establish- ing how symptoms fit together, how prevalent the symptoms are in the normal population, and what level of a specific dimension is statistically abnor- mal. Thus, for example, one can examine the con- struct of inattention across a normative sample and determine how frequent a person’s inattention is compared to age- and gender-matched peers. The advantages of this dimensional measurement is that it is cost effective and covers a broad range of behaviors, the dimensions are empirically derived, quantitative information is obtained for group comparisons and measures of change, and, as just noted, normative comparisons with age- and gender-matched peers is obtained.

MAKING THE DIAGNOSIS OF ADHD IN ADULTS

In our Attention Deficit Disorder Program, a clinical practice located in a university medical

Diane E. Johnson and C. Keith Conners

school, we have applied the AACAP practice par- ameters (1997) in the following ways. When an adult calls for an assessment appointment, we send them a packet of materials that must be com- pleted and returned to our clinic before we schedule an appointment. We request that the identified adult call and discuss this appointment; we do not accept parents or spouses calling in for their loved ones. We have found that contact with the identi- fied person results in better compliance and follow- through. The assessment packet is mailed to the individual, or the person may pick it up if so de- sired, in an attempt to collect as much “free” infor- mation ahead of time for which the patient is not billed. The packet contains a cover letter with an explanation of the assessment visit, a request to discontinue any psychostimulant A D H D medica- tion the day of the visit with their physician’s ap- proval, a request for any past records from school, psychological or medical evaluations, and/or work reports, and directions to the clinic. The assessment packet contains the following three assessment in- struments: a developmental history, self- and col- lateral rating scales, and a parent rating scale.

A detailed developmental history form that re- quires written responses or endorsements is in- cluded. This history form begins with gestational information and ends with current adult informa- tion. With regard to childhood and childhood risk factors, the history form includes questions about family of origin, gestational risk factors, delivery risk factors, temperament risk factors, developmen- tal risk factors, environmental risk factors, medical history, academic history, psychiatric history, and family history. With regard to adulthood, the his- tory form includes questions about educational/aca- demic history, occupational history, social/ interpersonal history, health history, psychiatric his- tory, comorbid psychiatric screeningquestions, sub- stance use, and current environmental stressors.

The history form we developed is our attempt to create a comprehensive developmental history for diagnosing adult ADHD. The Conners Adult ADHD Diagnostic Interview for DSM-IV (CAA-

4. The Assessment Process: Conditions and Comorbidities

tom presence if a significant other is not available at the time of the assessment or by telephone follow-up. It has been our experience that many adults have difficulty bringing a significant other with them to the assessment appointment due to issues of conflict or confidentiality.

The third and final measure included in the packet is a parent rating scale to be retrospectively completed by the parent or a person who knew the adult as a young child. That rater must be older than the adult being assessed by at least several years. While several childhood ADHD Parent Rating Scales exist, we use the Conners Parent Rating Scale-Revised, Long Form (CPRS-R:LF; Conners, 1997). However, we use the scale in a different manner than it is currently marketed. We change the instructions of the instrument so that it requires the “parent” to rate the adult offspring’s ADHD behaviors based on when their child was between the ages of 7 and 15 years. There is no normative data to score the CPRS-R as a retro- spective report; however, standard scoring pro- vides a parent rating of retrospectively reported childhood behaviors along several dimensions, including: Oppositional, Cognitive P r o b l e m s h – attention, Hyperactivity, Anxious-Shy, Perfection- ism, Social Problems, and Psychosomatic. These scores can be compared to how parents currently rate their children, providing some dimensional information about externalizing and internalizing childhood behaviors. Also, embedded in the meas- ure are the 18 DSM-IV diagnostic symptoms use- ful in determining early childhood diagnostic criteria.

Underreporting of childhood ADHD symptom- atology has been well documented (Wender, Reim- herr, & Wood, 1981; Barkley, Fischer, Edelbrock, & Smallish, 1991). Wender and colleagues (1981) found poor agreement between the recollections of adult patients and those of their parents of ADHD symptoms during childhood, with parental recall being a more valid measure as well as a better predictor of treatment response. Biederman and colleagues (Biederman, et al., 1993; Biederman,

DID; Conners, Epstein, & Johnson, 2001) is an empirically based structured interview that aids the process of diagnosing ADHD. The Interview is divided into two parts, administered separately. The first part, which can be administered as either a clinical interview or a self-report questionnaire (as we use it), is the developmental history question- naire. Having the patient complete the question- naire ahead of time is less time consuming for the clinician, allows the patient to gather information from others if necessary, and allows the patient to break the task into smaller sections if necessary. Whether the patient completes the history form beforehand or in the waiting room, the history form takes about 45-60 minutes to complete. As a clinical interview, it can take much longer, since open-ended questions are difficult to answer and fatigue increases distractibility.

Also included in the packet is an adult ADHD self-report rating scale and an adult ADHD collat- eral rating scale. Both scales rate current frequency of ADHD and ADHD-related behaviors. While there are several rating scales on the market and/ or published in the literature, we use the Conners Adult ADHD Rating Scales (CAARS; Conners, Erhardt, & Sparrow, 1999). These instruments pro- vide reliable and valid assessment of ADHD-re- lated symptoms across clinically important domains (home, work, and interpersonal function- ing), discriminate between clinical and nonclinical groups, allow for multimodal assessment (self- report and significant other’s report), have short forms for research settings, are linked to the DSM-IV (APA, 1994) diagnostic criteria, and have parallel structure with the Conners Parent and Teacher Rating Scales-Revised, which are used in making childhood ADHD diagnoses. The CAARS- Self and-Other Rating Scales are based on a large normative database of 2,000 adults. These scales are easy to administer and score. Additionally, patients have benefited from being educated about their ADHD symptoms in relation to other same gender age mates. The CAARS-Other Rating Scale allows us to gather information on current symp-

Faraone, Knee, Munir, & Tsuang, 1990), on the other hand, have demonstrated that a reliable and valid clinical diagnosis of childhood A D H D can be made based on self-report.

Once the packet is returned, the patient is called andanappointmentscheduled.Theratingscalesare scored before the appointment and put in the clinical chart with the developmental history form. A re- minder call the week before and sometimes the day before is helpful. Once the adult arrives for the as- sessment appointment, but before the person sees the clinician, she or he is asked to complete a compu- terized version of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1997).Thiscomputerizeddiag- nostic interview requires that the patient answer yes/ no questions related to the past and current presence of a variety of psychiatric disorders, including mood, anxiety, substance-related, psychotic, somatization, and eating disorders. While this instrument can be administered as a paper-and-pencil interview, in the clinicwehavefounditmoretimeandcosteffectiveto administer the interview via computer and then to follow up during the clinical interview. The patient can usually complete the diagnostic screen within 30 minutes.

We sometimes ask the person also to complete a computerized Axis I1 (personality disorders) diag- nostic screening interview. However, since we have found that the personality disorder questionnaires often overdiagnose individuals, we usually evaluate Axis I1 disorders as part of the clinical interview. It is often difficult to determine in one session whether or not a person has a personality disorder, espe- cially when the person is presenting with Axis I symptoms. Thus, past psychological/psychiatric treatment records are often helpful.

Once the SCID findings have been printed, the clinician reviews the findings, along with the his- tory form and rating scales. The clinical interview includes a review of the previously completed his- tory form (e.g., in the case of our clinic, the Con- ners Adult ADHD Diagnostic Interview for DSM- IV, Part I). In reviewing the history questionnaire,

Diane E. Johnson and C. Keith Conners

we ask for additional information about positive responses as well as observe the patient’s response style. Next, we follow up on the computerized DSM-IV Axis I questionnaire and, if completed, the Axis I1 diagnostic screening. The final part of the diagnostic interview is the completion of Part I1 of the Conners Adult ADHD Diagnostic Interview for DSM-IV (Conners, Epstein, & Johnson, 2001). The interview guides the clinician through the DSM-IV criteria. It provides the clinician with commonly reported examples of the 18 A D H D symptoms in childhood and adulthood, prompts for the pervasiveness of the symptoms across the life span, and contains operationalized guidelines that aid the clinician in assessing domains of im- pairment, due to ADHD, in childhood and adult- hood. Thus, the CAADID can also be used to assess ADHD in children and adolescents.

It is important to note that there are a variety of other structured interviews and rating scales avail- able to the clinician. Formats for such interviews have been published by Barkley (1990) and Man- nuzza and Klein (1987). Other adult ADHD rating scales include the Brown Attention-Deficit Dis- orders Scales (Brown, 1995), the Patient Behavior Checklist (Kane, Mikalac, Benjamin, & Barkley, 1990), and the Wender Utah Rating Scale (Ward, Wender, & Reimherr, 1993).

No other information or testing is completed routinely, but an assortment of tests or information may be necessary. If the person is overdue for a physical, especially if a medical condition is present or changing, one may be requested prior to concep- tualizing the person’s difficulties in a final formula- tion. We may request to speak to a parent, spouse, coworker, or treatment provider in some cases, or we may request further neuropsychological or vo- cational assessment. We would obtain a signed release before contacting anyone. We do not rou- tinely complete a neuropsychological battery on these adults because the literature does not support that any testing in and of itself is conclusive. How- ever, the results and observations of a continuous performance test (CPT) are often helpful. Within

4. The Assessment Process: Conditions and Comorbidities

two to three hours of the person’s arriving at the clinic, feedback is given to the individual, with referrals as necessary. An explanation of ADHD is given to the person in a multimodal presentation (charts and pictures as well as verbal explanations) and questions are answered. A packet of psychoe- ducational materials is given to the adult with ADHD that includes a variety of resources (books, Web sites, local organizations), information about ADHD and treatment options, educational rights of the person with ADHD, and strategies for cop- ing with ADHD. A written report is generated that documents the assessment. This report is mailed to the patient following the visit.

In an effort to translate the information in this chapter to practice, it may be helpful to review other adult ADHD assessment protocols, such as Murphy & Gordon’s (1998) published protocol from the University of Massachusetts.

GUARD1NG AGAlNST OVERDlAGNOS1NG ADHD IN ADULTS AND THE ISSUE OF COMORBIDITY

Murphy (1994) notes that diagnosing ADHD in adults is not an exact science. There is no single neurological or psychological test or test battery that can conclusively determine whether or not an adult has ADHD. The very limited amount of controlled research on adult ADHD, the lack of reliable and valid rating scales, and the fact that almost everyone at times experiences some of the symptoms of ADHD make overdiagnosis a con- cern. Murphy goes on to report that liberally diag- nosing ADHD in adults can have significant social, academic, vocational, and/or legal implications and can potentially undermine the efforts of those who do have the disorder. By way of summary, we might reemphasize the points made by Murphy (1994, pp. xxx, 3-4):

Remember that ADHD is a neurobiological disorder characterized by developmentally inappropriate levels of

sustained attention, impulsivity, and hyperactivity with a childhood onset.

It is chronic and pervasive and causes significant impairment in functioning. There should be evi- dence that the person meets DSM-IV criteria and there should also be no lengthy period of remis- sion from the symptoms without an explanation (such as no symptom impairment for the two years the adolescent was in military school due to environmental modifications).

ADHD does not have an onset in adulthood.

Keep the primary symptoms of inattention, impul- sivity, and hyperactivity in the forefront.

Secondary symptoms such as procrastination, chronic lateness, or underachievement do not, in and of themselves, indicate ADHD. Murphy (1994), as well as others, have noted that it is not uncommon for parents of ADHD children to pre- sent for assessment because they were aware of the genetic and familial component of ADHD, and not necessarily because they were troubled by symp- toms.

Beware of adults who may be looking for ‘perfom- ance enhancement.’

Beware of adults who may have something to gain by securingan ADHD diagnosis,

whether it is to qualify for special accommodations on professional licensing examinations or to obtain stimulant medication for recreational use.

Pay careful attention to other diagnoses that may ac- count for the symptoms,

especially depression, anxiety, substance abuselde- pendence, or antisocial personality disorder.

In conclusion, assessing the adult for ADHD is not an exact science, and one must rely on one’s clinical experience and expertise in discerning whether or not the person’s complaints of inatten- tion and/or hyperactivity-impulsivity are the result of continuing ADHD symptoms from childhood, another psychiatric or medical condition, or simply the natural result of the aging process. The field of

adult ADHD is only one decade old, and further research is needed in the areas of assessment and treatment.

It has been our clinical experience that providing an accurate diagnosis of adult ADHD, particularly in adults who were not identified with ADHD in childhood, can be therapeutic in and of itself. These individuals often report immediate relief once they have a framework in which to explain their lifelong difficulties academically, at home, socially, and/or personally. After a lifetime of believing that they are unintelligent, unmotivated, lazy, or inexplic- ably different from others, the diagnosis may be welcomed. They will need to further educate them- selves about ADHD and to discuss treatment options. Sometimes, mixed with relief are over- whelming feelings of sadness or anger because so much time has passed without ADHD being iden- tified. In order to accurately provide information to patients, clinicians must remember to abide by the DSM-IV diagnostic criteria and to uphold the AACAP practice parameters, which represent the only published guidelines for assessing adult ADHD to date. We believe that comprehensive self-education is the prerequisite to effective self- management by the adult with ADHD. It is the responsibility of clinicians to provide accurate diagnosis, education, support, and treatment as a critical foundation for both.

American Academy of Child and Adolescent Psychiatry. (1997). Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/ hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 36(Suppl. lo), 85s-121s.

American Psychiatric Association. (1994). Diagnostic and statis- tical manual ofmental disorders (4th ed.). Washington, DC: American Psychiatric Press.

Barkley,R.A.(1990).Attentionde$cit hyperactivitydisorder:A handbook f o r diagnosis and treatment. New York: Guilford Press.

Barkley, R. A,, Fischer, M., Edelbrock, C. S., & Smallish, L. (1991). The adolescent outcome of hyperactive children diag-

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nosed by research criteria. 111. Mother-child interactions, family conflicts and maternal psychopathology. Journal of Child Psychological Psychiatry, 32, 233-255.

Biederman, J., Faraone, S. V., Knee, D., Munir, D., & Tsuang, M. T. (1990). Retrospective assessment of DSM-I11 atten- tion deficit disorder in non-referred individuals. Journal of Clinical Psychiatry, 51, 102-107.

Biederman,J.,Faraone, S.V.,Spencer,T.,Wilens,T.,Norman, D.,Lapey,K.A.,Mick,E.,Lehman,B.K.,&Doyle,A. (1993). Patterns of psychiatric comorbidity, cognition, and psycho- social functioning in adults with attention deficit-hyperactiv- ity disorder. American Journal ofPsychiatry, 150,1792-1798.

Brooks, R., & Goldstein, S. (2001). Raising Resilient Children. New York: Contemporary.

Brown, T. E. (1995). Brown Attention-De$cit Disorders Scales. San Antonio, TX: Psychological Corp.

Comers, C. K. (1997). Comers’Parent Rating Scales-Revised. North Tonawanda, NY: Multi-Health Systems.

Comers, C. K., Epstein, J., and Johnson, D. (2001). Comers’ Adult ADHD Diagnostic Interviewfor DSM-IV (CAADID). North Tonawanda, NY: Multi-Health Systems.

Comers, C. K., & Erhardt, D. (1998). Attention-deficit hyper- activity disorder in children and adolescents. In A. S. Bullack & M. Hersen (Eds.), Comprehensive clinical psychology, 5 (pp. 487-525). New York: Elsevier Science.

Comers, C. K., Erhardt, D., & Sparrow, E. (1999). Comers’ Adult ADHD Rating Scales. North Tonawanda, NY:Multi- Health Systems.

First, M. B., Spitzer, R. L., Gibbon, M., &Williams, J. B. W. (1997).Structured ClinicalInterviewfor DSM-IVAxis IDis- orders-Clinician Version. Washington, DC: American Psy- chiatric Press.

Hartsough, C. S., & Lambert, N. M. (1985). Medical factors in hyperactive and normal children. American Journal of Orthopsychiatry, 55, 190-201.

Hinshaw, S. P. (1994). Attention deficits and hyperactivity in children. Thousand Oaks, CA: Sage.

Kane, R., Mikalac, C., Benjamin, S., & Barkley, R. A. (1990). Assessment and treatment of adults with ADHD. In R. A. Barkley (Ed.), Attention de$cit hyperactivity disorder: A handbook for diagnosis and treatment (pp. 613-654). New York: Guilford Press.

Mannuzza, S.,&Klein,R.G.(1987).Schedulefortheassessment of conduct, hyperactivity, anxiety, mood, andpsychoactive sub- stances (CHAMPS). New Hyde Park, NY: Children’s Be- havior Disorders Clinic, Long Island Jewish Medical Center.

March, J. R., Wells, K., & Comers, C. K. (1995). Attention- deficit/hyperactivity disorder: Part I. Assessment and diag-

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Sallee, F. (1995). Attention-de$cit/hyperactivity disorder in adults. Champaign, IL: Grotelueschen Assocs.

Waid, L. R., Johnson, D. E., &Anton, R. F. (1997).Attention- deficit hyperactivity disorder and substance abuse. In H. R. Kranzler & B. J. Rounsaville (Eds.), Dual diagnosis and treatment: Substance abuse and comorbid medical andpsychi- atric disorders (pp. 393425). New York: Marcel Dekker.

Ward, M. F., Wender, P. H., & Reimherr, F. W. (1993). The Wender Utah Rating Scale:An aid in the retrospective diag- nosis of childhood attention deficit-hyperactivity disorder. American Journal of Psychiatry, 150, 885-890.

Wender, P. H. (1995). Attention de$cit hyperactivity disorder in adults. New York: Oxford University Press.

Wender,P.H.,Reimherr,F.W.,&Wood,D.R.(1981).Atten- tion deficit disorder (“Minimal brain dysfunction”) in adults. Archives of General Psychiatry, 38, 449-456.

World Health Organization (1992). International statistical clas- sijication of diseases and related health problems (10th Rev.). Geneva:Author.

Zametkin, A. J. (1989). The neurobiology of attention-deficit hyperactivity disorder: A synopsis. Psychiatric Annals, 19, 584-586.

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Tsuang, M. T. (1995). Attention deficit hyperactivity dis- order and comorbid disorders: Issues of overlapping symp- toms. American Journal of Psychiatry, 152, 1793-1799.

Murphy, K. (1994). Guarding against over-diagnosis of ADHD in adults. ADHD Report, 2, 3-4.

Murphy, K., & Barkley, R. A. (1995). Preliminary normative data on DSM-IV criteria for adults. ADHD Report, 3, f%7.

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Murphy, K. R., & Gordon, M. (1998). Assessment of adults withADHD.InR.A.Barkley(Ed.),Attention-de$cit hyper- activity disorder: A handbook for diagnosis and treatment (2nd ed., pp. 345-369). New York: Guilford Press.

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Differential diagnosis of Adult A D H D is a com- plex and formidable challenge, for a number of reasons. (1) The symptoms of A D H D are core symp- toms of human nature that we all experience at times (Murphy & Gordon, 1998). It is not necessarily pathological to occasionally experience inattentive- ness, impulsivity, forgetfulness, or disorganization. (2) As we are all aware by now, most adults with A D H D also have comorbid psychiatric conditions that can complicate the assessment process and in- fluence treatment decisions. Disentangling ADHD from other psychiatric diagnoses, such as mood and anxiety disorders, substance abuse, and situational/ environmental stressors, can be a difficult challenge for even the most seasoned diagnostician. (3) The term clinically signlJcant impairment means differ- ent things to different people. How inattentive or impulsive does one have to be to meet the threshold for a clinical diagnosis? Measuring impairment and quantifying when a patient’s symptoms cross over the line into abnormal involves a certain degree of subjectivity and clinicaljudgment. Obtaining a con- sensus among professionals onjust where this stand- ard lies on the impairment continuum is an ongoing challenge and a source of significant controversy.

Clinician’sGuideto Adult ADHD: AssessmentandIntervention ISBN0-12-287049-2

(4) The diagnosis of A D H D in adulthood hinges heavily on childhood history, which can be difficult to obtain. In addition, reliance on self-reported memories of childhood symptoms may be vulner- able to inaccuracy, distortion, and incompleteness. (5) The increased awareness and popularity of the disorder, combined with the paucity of scientific research to date, has resulted in much folklore, myth, and misconception about adult ADHD among both patients and professionals. What we know about this disorder from results of sound em- pirical research is still extremely limited.

With these cautions in mind, themain purposes of this chapter are (1) to illustrate some of the more common challenges that arise in the assessment of Adult ADHD, (2) to discuss how these challenges were conceptualized and resolved, (3) to describe the rationale for the assessment/treatment decisions rendered, and (4) to underscore the importance of doing a credible and thorough assessment. I have chosen actual case examples ofpatients treated at the UMASS Adult ADHD Clinic in an effort to impart practicalclinicalinformationtocliniciansinterested in learning more about the nuances of assessing and treating Adult ADHD. These cases have been

Clinical Case Studies

Kevin Murphy Ph.D.

chosen to highlight important and useful “in the trenches” wisdom and are representative of the range of assessment and treatment issues that clin- icianswilllikelywrestlewithinpractice.Itismyhope that through these clinical cases, practitioners will not only gain a greater appreciation for the complex- ity of issues they will encounter in assessing and treating adult ADHD, but also learn to think more critically and intervene more effectively.

CASE ONE: ASSIGNING THE ADHD DIAGNOSIS INCORRECTLY CAN CAUSE HARM

Susan was an attractive 20-year-old singlecollege sophomore referred by her mother (a social worker) for further evaluation of an attention deficit hyper- activity disorder that had been diagnosed by her pediatrician the previous year. They were seeking a more comprehensive evaluation and a second opin- ion on the ADHD diagnosis. Susan reported long- standing problems with inconsistent concentration, easy distractibility, forgetfulness, restlessness, fidgeting, and disorganization that dated back to early childhood. These symptoms caused a great deal of frustration and a feeling that she was not working up to her full potential. Her mother con- sulted with Susan’spediatrician after Susan reported having unexpected difficulty studying and getting her work done during her freshman year of college. She had trouble listening to class lectures, day- dreamed, had great difficulty remembering what she read, was physically restless, and could not seem to stay seated for an entire class. Her mother recognized these symptoms as being consistent with ADHD and wanted to determine (1) if ADHD was causing these problems and (2) what could be done aboutthem.ThepediatriciandiagnosedADHDand prescribed Ritalin, which Susan found helpful.

So far, on the face of it this sounds very much like the prototypical set of ADHD symptoms we so rou- tinely hear from patients. Almost all adult ADHD evaluations have some of this sort of “face validity”

Kevin Murphy

to them, especiallywith respect to self-reported sym- ptoms. But as you will see, clinicians need to go well beyond simple symptom endorsement to make a va- liddiagnosis.DoesthispersonhaveADHD?Whyor why not?Isthere enough information here to reliably establish the disorder? Are there any other psychi- atric disorders that might better account for the symptoms?What other kinds of information would youneed to have before you could be more certain of the diagnosis? Even if she has ADHD, are there any comorbid conditions that can also be identified?

Let’s take a closer look at the details of this case. On what basis was the initial A D H D diagnosis made? The pediatrician’s 1 112-page report was based on a single 30-minute meeting with Susan and her mother. Here are selected passages from the pediatrician’s actual report copied verbatim.

Susan is a 19-year-old young woman who is referred for evaluation in the ADHD Clinic. Susan’smother, who accompanied her to the visit, said that she had noticed that she was always fidgety and considered her energetic and “flakey” at times. She noted she has a tendency to misplace things and forget things. Susan herself reports being easily distracted when she is trying to concentrate on her work or studying. She had maintained good grades through high school, but had a difficult time in college this year. During the school year, she on one occasion took a friends Ritalin and found that she was very focused for studying when she took it.

Subsequently, a family friend who is a physician gave her a prescription for Ritalin, sustained release, 20mg, which she took on an as-needed basis for school projects and for studying and found it helpful. She has not had any side effects as far as anorexia or sleep problems when taking the medicine.

As she has been growing up, Susan has suffered no serious illnesses and has never required hospitalization. She has had some minor trauma, but none with neuro- logical sequelae.

Developmentally, Susan met her early milestones of motor and language development at appropriate times. She also developed independence skills appropriately and had done well academically through most of her school years. Susan’s mother feels that Susan’s father may have had some similar problems as they are encountering in Susan. No one else in the family is known to be affected. Her general physical examination was normal, and she appears to be in good general health.

5. ClinicalCase Studies

mail with a signed consent accompanying Susan’s request that her records be sent to our clinic.

Relevant History

Susan’s developmental and health histories were normal and unremarkable. She had no mood, beha- vior, or temperament problems as a child and had no problems with peer relationships. She had no prior psychiatric difficulties or treatment until her fresh- man year of college, when she sought some brief counseling for low-grade depression symptoms. She denied any history of anxiety symptoms, suicidal ideation, psychosis, or eating disorders. She has had several summer jobs and reported no history of any vocational impairment. However, what became ap- parent over the course of the assessment was that she was having some problems with substance abuse. She had been using marijuana on a daily basis since eleventh grade and had been using alcohol regularly since then as well. On the Young Adult Self-Report Form she indicated she had been intoxicated 65 out of the past 90 days, had used marijuana every day, and had also experimented with other drugs on oc- casion. Susan stated her substance use may have aff- ected her motivation, but denied that it was affecting her academics because of how well she had done his- toricallyinschool.AlthoughhermotherknewSusan hadused alcohol and triedmarijuana, shehad no idea of the extent of her abuse. Other symptoms Susan described included never feeling satisfied, feeling indecisive about her future, restless sleeping, feeling unfocused and lazy, feeling like she does not fit in with her peers, and fearing that she would never find a special boyfriend that she could connect with. She added that she tended to hang out with friends who did a lot of partying because she found other peers who were more serious about school to be boring.

School History

Susan had completed her sophomore year at a largemidwesterncollege.Shehad alwaysperformed

I feel that Susan’s symptoms are consistent with adult attention deficit disorder and she has had a positive response to Ritalin. I therefore provided her with further prescription for Ritalin of 20mg sustained-release,which she will now use on a daily basis in the morning before class. She will use a second tablet later in the day as needed for course work or studying. I will see Susan back in approximately 3 months’ time, depending on her school schedule, to find out how things are going and to give her further prescriptions if appropriate.

Dr’s signature

Unfortunately, this type of an evaluation is not at all uncommon. For a variety of reasons, includ- ing the constraints of managed care, clinicians often do not have the time, training, or resources to conduct the kind of comprehensive evaluation that is necessary to accurately diagnose ADHD. This pediatrician’s thinking probably went some- thing like this: She and her mother are self- reporting all the right symptoms, which they say have been evident since childhood, and she has responded positively to her friend’s Ritalin. She probably has ADHD, so why not treat her with medication in an effort to help? What’s the harm? As you will see, misdiagnosing someone with ADHD can have negative consequences and may not be just a benign mistake.

I will now provide more of the history and details of this case that emerged from my more thorough evaluation of Susan. My evaluation in- cluded a comprehensive diagnostic interview with Susan and her mother, current and retrospective versions of the ADHD Rating Scale completed by Susan and her mother, and some testing, which was primarily for research purposes. The testing in- cluded an intellectual screen (Shipley), the Wide Range Achievement Test, the Nelson Denny Read- ing Test, the SCL-90-R, and the Conners Continu- ous Performance Test. Another critical aspect of my evaluation was inspection of her past school records, including her kindergarten record, elemen- tary and middle school report cards, high school and college transcripts, and prior achievement test scores. Her mother brought in some of these records, and the rest were obtained through the

exceptionally well in school (A’s and B’s) and was always in accelerated and gifted classes. Her college GPA was 3.8, and she graduated near the top of her high school class. She never repeated a grade, was never considered a discipline/behavior problem, had no problems with peer relationships, and consist- ently did her homework. Her early school report cards documented no history of academic or behav- ior problems. To the contrary, her report cards were filled with teacher comments showing her to be a cooperative, conscientious, well-mannered, atten- tive child who was well liked by her classmates and a pleasure to have in class. Other quotes taken dir- ectly from her records included “effort is outstand- ing, citizenship is exemplary, mature, responsible, self-motivated, enthusiastic, and fine attitude.” In short, her overall school history demonstrated ab- solutely no evidence of the types of symptoms or impairment that typically accompany ADHD.

Testing/Rating Scale Results

Susan’s overall testing results also showed no evidence of neurological dysfunction or attention problems, nor any impairment in learning. Her Shipley results yielded a composite score at the 92nd percentile, corresponding to the superior range of intelligence. On the Wide Range Achieve- ment Test Susan scored at the 88th percentile in reading, the 75th percentile in spelling, and the 98th percentile in arithmetic (achieving a very rare per- fect score on this subtest). On the Nelson Denny Reading Test Susan scored at the 83rd percentile in reading comprehension and at the 54th percentile in reading rate. Results of the Conners Continuous Performance Test were in the normal range. All of her prior standardized achievement test scores were in the above-average to superior ranges. Her SCL- 90 scores showed moderately elevated scores on the Depression and Interpersonal Sensitivity scales.

Interestingly, despite an objective history wholly unsupportive of having A D H D , Susan endorsed 10 of the 18 symptoms of ADHD for both current and

Kevin Murphy

childhood functioning on the ADHD Rating Scale. Her mother endorsed 8 of the 18ADHD symptoms for current functioning and 7 during childhood. So, although the history of functional impairment was not at all consistent with a developmental disability, both the patient and her mother saw Susan as ex- hibiting a significant number of A D H D symptoms throughout her life. Surprising? Not at all. Our data from a previous study (Murphy, Gordon, & Bark- ley, 2000) demonstrated just how common it is for normal adults to endorse ADHD symptomatology across the life span. In our community sample of 719 “normal” adults surveyed at two Department of Motor Vehicle offices in central Massachusetts, almost 80% reported experiencing six or more ADHD symptoms “at least sometimes” during childhood, and nearly 75% reported they were CUT- rently experiencing six or more ADHD symptoms “at least sometimes.” Large percentages of adults identify with at least some of the symptoms of this disorder; far fewer actually meet full DSM-IV diag- nostic criteria. As we have repeatedly emphasized in prior publications (Murphy & Gordon, 1998; Gordon & Murphy, 1998; Murphy & Barkley, 1996), diagnosing ADHD requires much more than simple symptom endorsement.

Does Susan have ADHD? Here is a summary of the major reasons why, according to DSM-IV, she does not meet criteria for ADHD.

1. It is quite clear she did not meet criteria for ADHD as a child, which is required to receive the diagnosis as an adult. There is no indication in her history that she experienced developmentally deviant problems with attention, self-control, or hyperactivity/ impulsivity.

2. Herschoolhistorywasnotatallreflectiveof the typical kinds of ADHD symptoms/ impairment that usually accompany ADHD. For example, she was always in gifted/ accelerated classes, graduated 13th in her high school class, and had a 3.8 GPA in college. Further, her objective school records clearly

5. ClinicalCase Studies

reason to continue. It was apparent that Susan was operating under the illusion that ADHD was her primary problem and was conceptualizing all of her difficulties in A D H D terms. This prevented her from focusing on the core issue she really needed to be addressing-the substance abuse. She later ad- mitted that the Ritalin was probably just helping her rebound from hangovers-activating her so she could study with less trouble. In her head, she attrib- uted her academic success in large part to the medi- cation and in that sense had come to rely on it. I was convinced that Susan was capable of excelling at school without the use of the medication (provided the substance abuse was under control) and believed it would be helpful to her in the long run to realize she could succeed on her own merits.

I also recommended Susan give some thought to spending more time with a different peer group, one that might have more in common with her regarding academics and future career potential. She had been hanging out with the wrong crowd at school, which was likely not helping her situ- ation. It was also suggested she seek some individ- ual counseling aimed at improving her self-esteem and interpersonal satisfaction, exploring/clarifying her personal, career, and academic goals, helping her reduce or eliminate her substance abuse, and for ongoing encouragement and motivation to stay on a positive track.

Although I had hoped that my evaluation and feedback had had a positive impact on Susan, it was not until several months later that I learned more about her outcome. While eating lunch in a local restaurant, I suddenly felt someone tapping my shoulder. I turned around and saw Susan’s mother. With tears in her eyes she grasped my hand and told me how grateful and thankful she was for my efforts at “setting Susan straight.” She went on to say that Susan had cut way back on her partying, had immediately stopped taking the Ritalin, had developed some new and healthier friendships, seemed more confident and self- assured, and was continuing to excel in school. She still did not have the boyfriend she wanted, but this

demonstrated she suffered no significant academic impairment historically and was a consistently high achiever who required no special help or accommodations to succeed.

3. Shehasexperiencednosignificantimpairment in work, social, or daily adaptive domains and clearly does not meet the impairment criteria required for a DSM-IV diagnosis.

4. Her symptoms appear to be better explained by a combination of other factors, including her chronic and daily marijuana use, alcohol abuse, and general personality factors.
Feedback Session

I chose to directly and emphatically explain to Susan and her mother all of the reasons why she did not have ADHD. I received permission from Susan to discuss the substance abuse issues with her mother present. In a rather forceful and unequivocal manner, I told Susan that I believed the substance abuse was affecting her moods, academics, motiv- ation, and overall functioning more than she was probably aware. I strongly recommended she elim- inate or at least drastically reduce her alcohol and marijuana use and, if she was unable to accomplish this on her own, to seek professional help immedi- ately. I pointed out and emphasized her extraordin- ary package of strengths and how unfortunate or even tragic it would be if she allowed her substance abuse to compromise or ruin her future. Now was the time to wake up and stop the progression into substance dependence-before it was too late. My tone was quite passionate, for I felt strongly that what happened in this feedback session could have huge implications on her future. Her outcome could go either way, and I believed that challenging her to make some critical lifestyle decisions, offering some strong guidance, and magnifying her impressive strengths just might help her set sail in the right direction.

Next, I recommended Susan discontinue her use of Ritalin, because there was no compelling need or

was no longer the travesty that she had viewed it as before. The fear that had been so evident in her mother’s face during our evaluation had been re- placed with relief and gratitude.

What are some of the lessondkey points this case teaches us?

1. It illustrates the importance and value of obtaining early objective historical records. Her paper trail of school report cards was indisputable proof that she did not have ADHD as a child. Without this sort of data, it would have been far more difficult to reliably establish the absence of a childhood onset of symptoms/impairment. It is crucial to keep in mind that ADHD is a develop- mental disability with a childhood onset that typic- ally results in a chronic and pervasive pattern of impairment in school, social, work, and daily adap- tive domains. Persons with bona fide A D H D will usually leave a trail of evidence in their wake as they go through life that is a testament to their developmentally deviant problems with attention, self-control, and/or hyperactivity. Where there is no impairment, there is no disorder. When histor- ical records offer no compelling record of impair- ment, it is difficult to justify an ADHD diagnosis.

2. It demonstrates the pitfalls of relying solely on self-reported symptoms and impairment. The pediatrician based the diagnosis exclusively on self-reports from Susan and her mother. Again, virtually all adult A D H D assessments have some “face validity” to them. Our challenge as clinicians is to move beyond the surface and make sure we thoroughly explore the key questions that are at the heart of a credible A D H D evaluation. Ideally, adult ADHD evaluations should strive to gather as much evidence as possible to address these key questions:

a. Are the symptoms of inattention, impulsivity, and overactivity clearly evident?

b. Is there objective evidence that these symptoms cause significant impairment in school, work, or social domains and in daily adaptive functioning?

Kevin Murphy

c. Have these symptoms been present since childhood? If not, is there a plausible explanation as to why the symptoms did not cause significant impairment until later (i.e., early treatment, accommodations, tutors, special school placement)?

d. Havethesymptomsbeenanenduringand consistent feature of this person’s behavior over time and across situations? If not, are there convincing reasons for the inconsistencies?

e. What evidence is there that the symptoms are not due solely to insufficient effort or motivation, poor vocational match, or transient situational or environmental circumstances/stressors?

f. Is the symptom picture better explained by some other psychiatric or medical diagnosis?

g. Isthereevidencethatotherpsychiatric conditions may coexist with the ADHD symptoms, and how would this affect the treatment plan?

3. It shows us never to assume that a previous professional’s diagnosis is valid. It is always prefer- able to conduct your own independent and objective evaluation with an openmind, attempting to address as many of the key issues listed earlier as possible with whatever resources are available to you.

4. ItillustratesthatapositiveRitalinresponseis not diagnostic of ADHD. In fact, most anyone who tried using a stimulant would report feeling more attentive and focused. The fact that Susan reported being able to study and focus better while on Ritalin in no way establishes that she has ADHD.

5. It shows the importance of clinician’s having a repertoire that includes being able to explain convincingly and effectively how and why the pa- tient does not have ADHD and what other diagno- sis may better explain their problems.

6. It reminds us to make sure we apply the full DSM-IV criteria (including the requirement for “clinically significant impairment”) as opposed to accepting self-perceptions of ADHD-like com- plaints as sufficient for establishing the disorder.

5. ClinicalCase Studies

However, he did indicate experiencing problems with peer relationships as a child and was often ridiculed and physically beaten by his peers. He had no history of any past or present significant health problems. His first marriage lasted seven years and ended in divorce. He was married to his second wife for ten years and had a 9-year-old daughter who had been recently diagnosed with ADHD. His father had an eighth-grade education, and the patient suspected that his father also had ADHD and learning problems.

Past Psychiatric History

The patient came to our clinic with an estab- lished diagnosis of bipolar disorder. He had been taking lithium 1800mg per day for the previous eight years. He had been hospitalized on two occa- sions at a Veteran’s Administration Hospital, which was where he received his bipolar diagnosis. Both he and his wife never believed this was an accurate diagnosis, wanted a second opinion, and wanted to explore ADHD as a possible alternative explanation for his longstanding problems.

The patient had been diagnosed with hyperactiv- ity in the sixth grade and was put on Ritalin for two years, with excellent results. He apparently stopped taking the medication after his doctor moved away and he could not find another doctor to prescribe for him. He was told he was too old to take Ritalin and would outgrow his symptoms. From the ninth grade on, he went untreated and continued to have on- going problems with self-control, academics, and peer relationships. He had been hospitalized in two different VA hospitals for depression and anxiety symptoms in the past. The first hospitalization oc- curred after he was informed he had a terminal dis- ease, which he later learned was not true. His “depression” disappeared immediately after this good news was confirmed and he was discharged. The second hospitalization occurred after a loud argument with his ex-wife when he was under the influence of alcohol. He was agitated and verbally

7. It informs us of the potential harm that mis- labeling someone as ADHD can cause. Had Susan gone on believing that her problems were due to ADHD, this would have prevented or further dis- tanced her from addressing her real problem. Her substance abuse would have continued to progress, she would have continued taking medication that was not necessary, her parents’ angst would have continued, and she would have continued to attri- bute her success to something other than herself, which would have further eroded her self-esteem. Moreover, if she ever requested academic or work- place accommodations in the future under the Americans with Disabilities Act and was required to submit documentation in support of her disabil- ity, it is highly unlikely she would be able to sub- stantiate either a diagnosis or a disability.

CASE TWO: ADHD OR BIPOLAR DISORDER OR BOTH?

(A version of this case was originally published in the Clinical Grand Rounds section of the ADHD Report, Vol6, No. 1, pp. 14-16, and is reprinted by permission of Guilford Press). The patient was a 37-year-old married male who was self-referred to our clinic. His daughter had been diagnosed with ADHD and while attending a local CH.A.D.D (Children and Adults with Attention Deficit Dis- order) meeting he discovered that ADHD was now being recognized and treated in adults. He had been diagnosed with hyperactivity as a child and had continued to experience problems with concen- tration, distractibility, following tasks through to completion, school performance, and maintaining successful employment. A review of his history indicated he had experienced longstanding A D H D symptomatology beginning in early childhood that had continued to plague him throughout his life. His developmental history was unremarkable in that he experienced no major temperament prob- lems as a child and reached all of his major devel- opmental milestones at age-appropriate times.

abusive and a neighbor called the police, who escorted him to the VA Hospital for evaluation. He reported using alcohol and marijuana while in the service but denied any current use or abuse. Thora- zine was prescribed during his second hospitaliza- tion, which he took only once due to negative side effects. He denied ever having any delusions or hal- lucinations, manic episodes, or obsessions/compul- sions. He described himself as extremely impulsive, disinhibited, argumentative, and hyperactive.

School History

The patient graduated from high school and attended several colleges over a 13-year period but was unable to complete a degree. He described a history of problems with school, including incon- sistent performance and grades, distractibility, impulsivity, poor concentration, poor reading com- prehension, hyperactivity, and peer relationship problems beginning in early elementary school. He had a history of performing below his potential in school, and his teachers always thought he could do better. He was placed in remedial reading classes during his earlier school years and stated he never was able to do homework. He had great difficulty sitting still, focusing, and sustaining his effort and concentration long enough to get anything done. School had always been a source of great frustra- tion for him, and he never understood why he was not able to achieve up to the level of most of his peers.

Vocational History

The patient estimated he had worked at well over a hundred different jobs in his adult life. He routinely held four or five part-time jobs at a time and would replace jobs as fast as he lost them. He needed constant variety and became easily bored with most of his jobs. He estimated that he had been fired from at least 50jobs in the past and had

Kevin Murphy

impulsively quit at least another 25. Most of his jobs were in the electronics and manufacturing fields. He had chronic problems with getting

along with coworkers and especially authority fig- ures and bosses. He always had great difficulty conforming to rules, was often late, and did what he wanted to do instead of what he was supposed to do. While in the service he had great difficulty following the rules and regimentation and was given an abrupt general discharge under honorable conditions after numerous reprimands.

Assessment Results

A summary of his results indicated that both he and his wife endorsed 16 of the 18 symptoms of A D H D currently. He endorsed the same number of symptoms for when he was a child. Intellectual assessment yielded an IQ in the above-average range, and his performance on the Wide Range Achievement Test indicated average to above-aver- age skills in math, spelling, and reading. Clearly, there was a marked differencebetween his measured intelligence and his history of poor school perform- ance. A careful review of his history suggested that he had never met full criteria for mania and had never met criteria for a major depression. There appeared to be little evidence to support a diagnosis of bipolar disorder. Although he did experience several periods of episodic depression, they were associated with situational precipitants and tended to resolve suddenly when circumstances changed. In short, there seemed to be little symptomatology in his history that would support a diagnosis of bipolar disorder and many indications of long- standing symptoms consistent with ADHD. Fur- ther, both he and his wife indicated lithium was not at all helpful. In fact, he indicated he had taken his lithium only sporadically for much of the past eight years due to his ambivalence about the bipolar diagnosis. It was also not clear that he had ever experienced a true manic episode. His wife of 12 years stated that she had never seen him exhibit

5. ClinicalCase Studies

manic symptoms, and she also doubted the bipolar diagnosis.

Treatment Decisions and Discussion

This case illustrates some of the difficulties in differentiating the hyperactive/impulsivesymptoms of ADHD from a mild form of bipolar disorder. In most cases, the vastly different symptomatology be- tween ADHD and classicbipolar I is not difficultto distinguish. For example, the markedly elevated mood, grandiosity, pressured speech,decreasedneed for sleep, hypersexuality, reckless spending, and in some cases psychotic symptomatology associated with a true manic episode are quite distinct from ADHD. However, it can be much more difficult to differentiate ADHD from a milder form of this mood disorder, such as bipolar 11, hypomania, or cyclothymia, where there is considerable symptom overlap with ADHD. In this case, the evidence sup- porting anADHDdiagnosisincludedthefollowing:

1. The patient and his wife endorsed a sufficient number of DSM.111-R symptoms.

2. He had received a diagnosis of hyperactivity during childhood.

3. He had a positive response to Ritalin for two years during childhood.

4. Despite his above-average intelligence, he had a longstanding history of poorluneven school performance.

5. He had a longstanding history of peer relationship problems.

6. He had problems maintaining consistent employment that appeared to be related primarily t o severe impulsivity, hyperactivity, and oppositionality.

7. ADHD was present in the family bloodlines (daughter diagnosed and father suspected of having ADHD).

8. Hisoverallhistorywasmoresuggestiveofa chronic and pervasive pattern of ADHD-like

impairment, which clearly began in early childhood, not the wide and cyclical mood swings, episodic bursts of productivity, grandiosity, insomnia, pressured speech, and excessive activity level/ reckless behavior associated with bipolar disorder.

On the other hand, evidence supporting a pos- sible bipolar disorder included the following:

1. 2.

4. 5.

Periods of episodic depression symptoms in the past.
Periodic explosive temper outbursts that may have resembled the agitation and mood lability of a mood disorder.

The patient had been prescribed 1800mg of lithium per day for the past eight years and had not experienced a major depression or manic episode since being on the drug.

He had been hospitalized on two previous occasions and diagnosed as having bipolar disorder.
His pattern of working several part-time jobs simultaneously and the sheer number of jobs, terminations, and impulsive quits could plausibly be viewed as stemming from hypomanic behavior.

He spent money impulsively (often on hobbies or “toys” that he quickly got bored with) that created a significant financial hardship for his family.

In our opinion at the time, there was more evi- denceto support an ADHD diagnosisthan a bipolar diagnosis. A detailed feedback session was con- ducted with the patient and his wife reviewing the reasons for both the ADHD diagnosis and the pos- sibility of the bipolar diagnosis. The patient and his wifeagreedwiththeADHDdiagnosisandexpressed a strong desire to pursue treatment for ADHD. An informed consent discussion was conducted with the patient and his wife outlining the possible risks and benefits associated with treating him for ADHD. Since we could not reliably predict the outcome or guaranteeapositiveresponse,itwaspointedoutthat

if he did have a form of bipolar disorder and was treated with a dopamine agonist such as Ritalin, there was a possibility of precipitating a manic epi- sode. Once he understood the potential risks and benefits and our informed consent discussion was documented, we proceeded with treatment.

We began by gradually tapering his lithium dose over several weeks until the lithium was discon- tinued altogether. Over the course of this withdrawal period the patient’s mental status was monitored closely to ensure that his mood remained stable. No evidence of manic symptoms emerged, so a Rita- lintrialof5mgTIDthreetimesadaywasstarted.He tolerated this well, reported no side effects, and reported an increased ability to focus and concen- trate. After one week, his dose was increased to lOmg three times a day. He continued to respond extraordinarily well with no appreciable side effects, and his dosage was increased to 15mg TID and eventually to 20mg TID. At no point in his treat- ment did he ever display symptoms of mania or a major depression. The Ritalin produced an immedi- ate and dramatic improvement in this patient’s day- to-day functioning.

Although we were not completely sure at the time whether he had ADHD alone or ADHD with a comorbid mood disorder, several clues emerged that suggested we were not treating a mood dis- order.

1. The patient had never believed the lithium was beneficial at any dose level.

2. No noticeable change in his mental status or moods occurred over the course of the lithium withdrawal.

3. Ritalin even at low doses produced dramatic and ongoing improvement in all aspects of his life.

4. Ritalin did not induce any manic-like symptoms.

5. No history of bipolar or mood disorder was present in the patient’s family bloodlines, but there was a positive family history of A D H D (daughter and possibly his father).

Kevin Murphy

6. He remembered having a poor response to a tricyclic antidepressant during his first hospitalization.

7. His overall improvement has continued for nine years, with no evidence of depression or mania.

The combination of going off the lithium, get- ting back on Ritalin, education about the disorder, and some supportive counseling improved his life in a most profound way. His accomplishments since beginning treatment for ADHD included the following.

1. He not only completed his undergraduate degree, but continued on to earn a Masters

3. 4.

degree, graduating with honors.
He currently has one job, and the revolving-

door pattern and problems with temper and impulse control at work have markedly improved.

His moods are more stable, and he is able to control his temper to a much greater degree. He is far less impulsive, is able to think ahead

and anticipate consequences more effectively, and is more financially secure since gaining better control over his impulsive spending habits.

His marriage is more solid and stable, and as a result of his improvement he and his wife agreed to have another child.

It has now been almost nine years since his adult ADHD diagnosis, and he continues to do extraor- dinarily well. He continues to take Ritalin 20mg three times a day and remains stable in his work and family life.

Parting Comments

This case again illustrates the importance of a thorough assessment and history taking when evaluating for adult ADHD. On the face of it, it is understandable how someone with his prior his- tory and behavior could have been viewed as

5. ClinicalCase Studies

cation and counseling, acceptance of their disability and learning not to devalue themselves because of it, peer group influences, problems with the law, and struggles with parents around autonomylindepend- encelmaturity issues.

Although research studies indicate the outcomes for this group are generally quite poor compared to teens with ADHD who do not have conduct or substance abuse problems, it is essential that all of us-parents, teachers, and professionals-not give up on them. Scientific studies report findings based on group data, not on any one individual. It is im- portant to remember that group data do not dictate the outcome of any one individual. It is therefore essential that we identify and assist those with ADHDICDlsubstance abuse, because underneath their problems they can, in some cases, be skilled, capable, productive people who contribute signifi- cantlytosocietyifproperlytreated.

The main purpose of this case is to convey the message that no one is hopeless and that even those with the poorest prognosis can sometimes defy the odds and turn things around. It is hoped that pa- tients with similar profiles can glean hope from this story and that clinicians will be reinforced never to give up on these most challenging cases.

Background Information

I began seeing J when he was 16 years old. He had been diagnosed with ADHD, conduct disorder, and polysubstance dependence a year earlier at the UMASS Child ADHD Clinic. He had a longstand- ing history of schoolllearning problems, disruptive and aggressive behavior, impulsivity, and severe at- tention difficulties beginning in very early child- hood. These problems led his mother to pull him out of public school after first grade and home- schooling him until the eighth grade. He began drinking alcohol at age 12 and shortly thereafter began abusing marijuana, acid, and crack cocaine. His attempt at public high school failed, and he ended up dropping out of school in nineth grade.

having bipolar I1 disorder or cyclothymia. Unfor- tunately, this patient struggled for years with a misdiagnosis of bipolar disorder and ineffective treatment. Another lesson evident from this case (as also mentioned in Case One) is not to automat- ically assume that a previous diagnosis from an- other professional is valid. It is always preferable to perform an independent and objective assessment and to gather your own data in support of your diagnostic conclusions as opposed to merely accepting another professional’s opinion. Accept- ing the previously established bipolar diagnosis as valid and failing to consider ADHD as a possible explanation for his difficulties would have been most unfortunate for this patient.

Although this patient still experiences A D H D symptoms, they have become far less disruptive, and the overall quality of his life has been dramat- ically improved. The components to his treatment and successful outcome included not just stimulant medication, but education about the disorder, sup- portive counseling, a supportive wife, making ap- propriate vocational and educational choices, and a lot of hard work.

CASE THREE: ADHD WITH COMORBID SUBSTANCE DEPENDENCEAND CONDUCT DISORDER

(A version of this case was originally published in the Clinical Grand Rounds section of The ADHD Report,Vol. 8,No. 3, pp. 14-16, andisreprintedwith permission of Guilford Press). Most clinicians are wellawarethatadolescentswithADHDandcomor- bid conduct problems and substance abuse are among the most difficultindividuals to treat success- fully. They present special and enormously difficult challenges and frustrations to parents, educators, and professional treatment providers. Some of the common issues these teenagers face include lack of understanding and denial of their disability, fear of being stigmatized and not being accepted, low self- esteem,treatment complianceissuesregarding medi-

J immediately began having problems with the law and had been in jail and juvenile detention centers several times before his 16th birthday for charges including auto theft, breaking and entering, assault and battery, and various drug charges.

One of J’s favorite things to do was to engage in fistfights. He loved the rush and excitement of a good fight and actively sought them out. His idea of fun on a Saturday night was to throw rocks at police cars because he “loved the chase.” J’s bio- logical father (whom he never knew) had a history of alcohol and drug abuse, behavior problems resulting in expulsion from high school, antisocial behavior, and incarceration. J seemed destined for a similar fate.

By the tender age of 17, J had already experi- enced five inpatient hospitalizations for substance dependence, was thrown out of several others for rule infractions, attended several other court- mandated outpatient treatment programs, was well known to all the local police, and had served sig- nificant jail time. He could not seem to follow through with anything. Many professionals in- volved in his treatment figured he would either be dead or permanently incarcerated by the time he was 21. He could not stay clean from drugs, would continually relapse after brief periods of sobriety, had a violent temper, hung around with the wrong people, had never worked at a competitive job, had no formal education, and was a source of intense frustration to his treatment providers. At least one of his doctors labeled him as ‘‘hopeless’’and “did not want to waste any more time on him.”

Initial Treatment Attempts

Despite this clinical picture, there was something about J that I found engaging and likable. I did not find him to be the intractable antisocial person- ality-disordered person that others had. Underneath his hard exterior was a charisma of sorts, an en- gaging spirit and personality, a great deal of “street smarts,” and a dry sense of humor. It seemed that a

Kevin Murphy

part of him wanted to find a way to turn his life around, but he just didn’t know how or where to begin. I began my work with him by focusing on his most pressing problem-his substance abuse. I was desperately trying to influence him to acknowledge his substance abuse problem and to work at main- taining sobriety. If he could remain clean for even a brief period, it might allow us to pursue a stimulant medication trial to concurrently treat his underlying ADHDsymptomatologyandcurbhissevereimpul- sivity.IalsoattemptedtoeducatehimaboutADHD to help him understand its relationship to some of his current and past problems. I tried to instill hope that if he could get clean and we could treat his underlying ADHD, he would see significant improvements in his life. Unfortunately, at that time he was not able to understand or accept the ADHD piece, and he con- tinued to struggle with sobriety and the law. Conse- quently, he was not able to achieve a degree of sobriety/stability that would have allowed us to safely medicate him for ADHD. Nevertheless, I hoped I had at least planted some seeds and stimu- lated him to begin thinking in a positive direction.

later Course

I continued to offer supportive counseling to J, but he eventually moved out of the area and I lost touch with him for several years. In the meantime, we began treating his mother for ADHD and she responded beautifully to Ritalin. I did not see J again until several years later. His mother had kept me abreast of his progress, which turned out to be truly remarkable. In short, despite some set- backs and struggles, J was able to find a way to turn his life around and sustain a positive direction in a way that no one thought possible. Today, at age 24, J is drug free, takes Ritalin on a regular basis, has maintained successful and steady employment as a chef, has stayed out of legal trouble, and appears to have a good chance at a bright future. How did someone with such a poor prognosis accomplish all of this? I asked J to sit down with me and discuss

5. ClinicalCase Studies

realize it is, and will continue to be, a key to his future success.

He found a supportive, straight, and healthy girl- friend who genuinely cared about him. This was a new experience for J. She apparently saw the good in him and made it quite clear she would not be a part of his life if he chose to use drugs. She was bright, responsible, and hard working, seemed to understand and accept him, and has been a dis- tinctly positive influence on J. It was indeed fortu- nate that he met her when he did, because at any other time in his life their relationship would never have happened. She provided some much needed structure and encouragement, they had a lot of fun together, and she believed in him. J also helped her in many ways, and they became best friends. They have begun to live together and are learning how to adjust to each other’s style and personal habits. So far, it seems to be going reasonably well.

He found a job situation that “fit” him, which allowed him to experience success. After working as a dishwasher and paying his dues for a while, J was offered a chance to start working as a prep cook, which he immediately excelled at. He loved the hands-on aspect of the job, the fast pace and excite- ment, the varied responsibilities, the physical move- ment required, and the opportunity to move to different resort locations periodically when the need arose. For example, he got to work in the kit- chens at Steamboat Springs, Colorado; Deer Valley, Utah; Key Largo, Florida; and Glacier National Park. He was transferred frequently enough so that he never was bored. He worked long hours, worked weekend nights, which helped him stay clean and out of trouble, and began learning as much as he could about the culinary trade. He made it a point to be polite and respectful to his bosses, and before long it became apparent that he was talented and highly valued. For the first time in his life he was having success in a competitive job, and he began making good money. His self-esteemcontinued to improve. He began assuming more and more responsibility

the factors that contributed to his unlikely and impressive turnaround. He gladly agreed, and here is what he told me.

Factors in His Turnaround

Getting clean from drugs. This was the founda- tion that allowed other positive events to occur in his life. He finally realized he had lost control and could not continue his familiar pattern and that his drug use was always associated with big trouble. He had been exposed to a great deal of substance abuse education in his prior inpatient and outpatient treat- mentbuthadnotbeenreadytomakethelifechanges required to succeed.With some added maturity and a growing realization that his way was not working, he decided he must begin to make some serious changes. J made a conscious decision that he wanted to live and be straight. With his reputation and his- tory, to have any chance of making it he felt he had to make a fresh start elsewhere. He moved away from his hometown (and the people, places, and influ- ences that helped keep him stuck) and went to a resort area, where he knew a friend who got him a dishwashing job. He began attending Alcoholics Anonymous and Narcotics Anonymous meetings and cut ties with all the negative influences and people from his past.

He began taking Ritalin. After witnessing his mother’s dramatic improvement while on Ritalin, J decided he had nothing to lose by trying it. He noticed an immediate improvement in his ability to focus, sustain his effort and concentration, and slow down. His impulsive temper was improved (but not cured), and he seemed to have generally better self-control. Although he did not respond quite as dramatically as his mother had, there was clearly a marked improvement in his overall func- tioning. He stated there is absolutely no way he would be able to perform his current job as a chef without the Ritalin. His current dose is 20 mg four times a day, and he, his mother, and his girlfriend

and eventually found himself in a head chef position supervising a staff of 33. His quick temper still inter- fered on occasion, but his overall performance was excellent.

Taking up karate. Coinciding with his new life was a decision to study karate. Since he always loved to fight, he was a natural, and it soon became his passion. He loved the philosophical part as much as the physical, and he eventually earned a black belt. It taught him self-discipline at a time when he greatly needed it, and the structure and commitment it required was also therapeutic. He competed in and won several tournaments and also became a karate teacher himself. His success resulted in his gaining some much needed self-re- spect and self-confidence. Between his work, the karate, and his girlfriend, he had little time or energy left to find any trouble.

His mother. Despite seeing her relatively infre- quently and a history of ups and downs with her, J always knew his mother loved him, saw the good in him, and was behind him. Although he often got angry with her (and especially his stepfather), he always respected her and knew she would never give up on him. It was comforting for him to know that deep down, no matter what kind of trouble he was in, she would always be there and would never abandon him. She was the one con- stant in his life when everything else seemed so unstable and chaotic. She helped him out of nu- merous jams, and as he has matured, J has gained more and more respect for his mother. In retro- spect, J has come to realize how important she has been and continues to be to him. No one is more proud of where he has come to today, and his mother has always been his number-one fan.

Luck. It never hurts to have some luck, and J has experienced his share of good fortune. He could have been killed or seriously injured in nu- merous situations and seems to have been in the right place at the right time on many occasions.

Kevin Murphy

Given the experiences and places he has been in the past and what could have been, he is the first to admit that he is indeed fortunate to be where he is today. On the other hand, to some extent he has also made his own luck. Armed with his good social skills and street savvy, J has made his own breaks by taking charge of opportunities that have come his way and capitalizing on them.

Social skills. J may have little formal educa- tion, but he has a Ph.D. in street smarts and social intelligence. He has always been “cool,” knows how to talk to and get along with all kinds of people, is likable and funny, and knows how to create opportunities for himself. He respects people who also show him respect, makes friends easily, and has made significant strides in learning how to reach out and be a friend to others. His interper- sonal style and ability has clearly contributed to his current success and will no doubt continue to be a valuable asset in the future.

Current Status and Future Goals

J continues to stay clean of drugs but does drink alcohol on occasion. Although he realizes the safest course is complete abstinence, his use of alcohol has stayed largely under control in recent years. He has a full-time job as a chef in yet another resort location, is living successfullywith his girlfriend, is physically active with his karate, has no current problems with the law, and is taking his medication consistently. He is considering pursuing his G E D and may even consider furthering his education in the future. Although his course has been anything but smooth and linear and he has had his share of setbacks, J has managed to overcome huge odds and turn his life in a positive direction. He seems to enjoy life now and can actually see a future for himself. Although the jury is still out on his long- term outcome, his attitude, motivation, and deter- mination to stay on a positive track bodes well for his future.

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the law. What do these words mean and what relevance do they have to mental health profession- als? How do we apply these principles to real-life cases?

If you are not exactly sure, you are not alone. In fact, most mental health professionals who submit documentation on behalf of examinees are unin- formed about the legislativeintent of the ADA and unfamiliar with the fundamental principles inher- ent in the ADA (Gordon & Murphy, 1998). This is not especially surprising given that (1) the law is only ten years old and its impact on higher educa- tion has begun to surface only relatively recently, and (2) continuing education training opportun- ities on the subject are not readily available.

But perhaps the largest source of error lies in our confusing special education laws (such as the Indi- viduals with Disabilities Education Act, or IDEA) with antidiscrimination laws (such as the ADA). Most clinicians are familiar with the IDEA, which is a special education law that dictates that children who underachieve due to a disability are entitled to remedial services that correct or circumvent defi- ciencies (Gordon & Murphy, 1998). A major goal of the IDEA is to facilitate success or a positive outcome. Its spirit and intent are consistent with how most clinicians and advocates have been trai- ned-to do whatever it takes to help students opti- mize their performance and reach their goals. However, a critical distinction between IDEA and ADA that is so often misunderstood is that this notion of creating conditions to facilitate success really has nothing to do with the ADA. Again, the ADA is intended to guarantee equal opportunity or equal access, not a successful outcome. Where the goal of the IDEA is to facilitate learning and opti- mize student achievement, the ADA is outcome neutral and addresses the responsibility of institu- tions to ensure that otherwise-qualified individuals are not discriminated against on the basis of a disability. Failure to understand this fundamental difference between these two laws is the source of much confusion, anger, and heartache among both students and their clinicians.

Conclusion

Despite the generally poorer outcomes of those adolescents with comorbid ADHD, conduct dis- order, and substance abuse, some, like J, do go on to achieve satisfactory outcomes. We need to strive to better understand the variables that are correl- ated with positive outcome and keep working at bringing them about. Clinicians can play a power- ful role in helping these adolescents learn ways to overcome their problems, by instilling hope, redu- cing discouragement and demoralization, and fostering a belief that they can be successful in school, work, and their future lives. They need to understand that they have a treatable condition and that they have some power, control, and re- sponsibility over how effectively they learn to manage it.

CASE FOUR: ADHD/LD AND TEST ACCOMMODATIONS FOR A PROFESSIONAL LICENSING EXAM: EFFECTIVE ADVOCACY

Attention deficit hyperactivity disorder has become an increasingly popular basis for seeking test accommodations under the Americans with Disabilities Act. The ADA is an antidiscrimination law whose goal is to ensure equal access and to level the playing field for individuals with disabilities (Gordon & Murphy, 1998). It serves to protect people who are otherwise qualified to perform the essential functions of a job from being discrimin- ated against solely on the basis of a disability. More specifically, the ADA states that to be considered disabled, a person must be “substantially limited (not mildly or trivially) in a major life activity” compared to the “average person in the general population.” Consequently, persons who demon- strate uneven performance or relative weaknesses in select areas that do not amount to a “substantial limitation” in a major life activity compared to most people are not considered disabled and are therefore not eligible for accommodations under

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Not only this, but due in part to some recent precedent-setting cases (Price v. National Board of Medical Examiners, 1997; Gonzalez v. National Board of Medical Examiners, 2000) and some recent Supreme Court decisions (Sutton v. United Airlines, 1999; Murphy v. United Parcel Service, 1999; Albertson’s v. Kirkingburg, 1999), the term disability is becoming more narrowly defined. The documentation requirements not only to adequat- ely substantiate a diagnosis, but to demonstrate that a person’s degree of impairment is sufficient to rise to the level of a disability, are quite rigorous and not commonly understood by the average diagnostician. Standard diagnostichesting reports done in the course of routine practice almost always

fall short of what is required to substantiate a dis- ability. Clinicians must build a compelling case based on a history of clinically significant func- tional impairment (preferably with prior objective records and not simply self-reported memories) that shows the person is substantially limited in a major life activity in comparison to most people in the general population. This is a difficult stand- ard to meet, especially in graduate school envir- onments, where most people, simply by virtue of being accepted into these highly competitive envir- onments, are functioning at a higher level than the “average” person. In short, the high-stakes issues surrounding ADHD, test accommodations, and the ADA are contentious ones that are poorly understood by most mental health profes- sionals.

This case illuminates and explains many of the concepts and key issues diagnosticians need to understand to substantiate a diagnosis and to establish a disability as this term is defined under the law. It will also point out some of the common mistakes mental health professionals make in their documentation efforts. My hope is that after digesting this case, clinicians will be better equipped to handle similar cases, better able to apply these principles in a fair and objective manner, and thereby be more effective clinicians/ advocates.

Kevin Murphy

Background Information

Tom was a 24-year-old single white male re- ferred by his parents. He had experienced problems with concentration, distractibility, impulsivity, and school/learning problems beginning in early child- hood. His developmental history was mostly unre- markable, with the exception of being delayed in talking. He was not able to combine words so others could understand him until age 4. His mother described him as extremely active, always on the go, impatient, disorganized, and a bit over- bearing at times. He had no significant health prob- lems. Both of his sisters had been diagnosed with ADHD, and Tom suspected his paternal grand- mother also had it.

Past Educational and Psychiatric History

Tom first saw a mental health professional during second grade due to poor school achievement. Des- pite a WISC-R Verbal IQ of 107,Performance IQ of 109, and Full Scale IQ of 109, his Core evaluation report from 1978 recommended he be held back in second grade, described him as distractible and having problems with reading, and documented a diagnosis of dyslexia. This was based on school records, parent input, and testing results that showed him to be functioning two years below grade level in reading. This educational testing report clearly spelled out the nature of his problems and described the types of errors he made (letter reversals, b d consonant confusion, poor oral read- ing not yet developed at the preprimer level, sequen- cing errors, substitutions, random guessing, poor word recognition, and distractibility). It provided a sound rationale for the diagnosis of reading dis- order/dyslexia and also described some early indica- tions of ADHD symptomatology. The report also made recommendations that logically flowed from the nature of the impairment. These included daily one-to-one reading instruction, tutoring, varying

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records and report cards, input from parents and tutors, and scores from prior standardized achieve- ment tests), and provided a rationale for the sug- gested accommodations that made good intuitive sense and logically flowed from Tom’s history of functional impairment.

Rationalefor Comorbid ADHD Diagnosis

Despite many of his past records describing ADHD-like symptomatology, Tom had never been diagnosed with ADHD. His problems had always been conceptualized as purely learning dis- abilities. Although I agreed that his primary prob- lems were in the realm of learning disabilities, I also felt there was ample evidence of comorbid ADHD that could be contributing to his academic and social difficulties. The evidence for the possible existence of ADHD included the following.

1. Tom endorsed 13 of the 18 symptoms of ADHD for current functioning and 15 of the 18 symptoms for childhood functioning.

2. His mother also endorsed 15 of the 18 ADHD symptoms for both current and childhood functioning.

3. His school report cards documented a con- sistent pattern of ADHD symptomatology and im- pairment throughout his school history, including excessive talking, distractibility, inconsistent effort, not working up to potential, problems with con- duct and self-control, being unprepared for class, and trouble completing homework.

4. His distractibility, forgetfulness, restlessness, and disorganization had interfered in his prior work history, resulting in inconsistent performance reviews. He was bored easily and had great difficulty doing what he termed mindless and repetitive work. He also had problems with listening, interrupting, impatience, and losing things frequently, both in school and in work situations. He vowed he could neverdoajobwherehewasrequiredtositatadesk

the pacing of material and teaching style, use of multisensory teaching techniques for phonics and sight word learning, ongoing informal assessments of progress, and reevaluation in one year’s time. Future evaluations and testing continued to validate the ongoing nature of his problems and the types of interventions, accommodations, and compensatory strategies he utilized. For example, his documenta- tion indicated he had been receiving resource room assistancefivetimesaweekforreading,spelling,and auditory memory throughout elementary school, had worked extensively with tutors on organiza- tional strategies, on proactive planning, and on com- pleting long-range assignments, and had received tutoring in algebra and foreign languages after fail- ing both in high school. He had also decided early on to learn to type using a word processor and to use spell-check due to his poor handwriting and severe spelling problems (also well documented).

Tom provided another report from a psycholo- gist he saw in tenth grade that summarized all of his prior evaluations and validated his ongoing and continued functional impairment. It also described additional details, including problems with self- esteem arising from his school problems, his anger at having been labeled with a disability and his difficulty accepting this, and his resentment at having to spend so much time with tutors and in resource rooms. This report spelled out a series of recommendations that included extended time on tests, private tutoring, waiving his high school’s foreign language requirement, encouraging him to use spell-check, grammar-check, and a word pro- cessor, and exploring colleges that have a reputa- tion for understanding and accommodating students with his types of challenges. Further, it documented his parents’ desire for him to attend a year at Landmark School (a special school for students with ADHD and/or LD) to consolidate his skills before taking on the challenges of college. Again, this psychologist’s report clearly explained the longstanding nature of his problems, included concurrent validation of his difficulties from mul- tiple sources (several prior testing reports, school

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all day. After a few trials doing office-type work, he ended up doing landscaping during summers be- cause it offered some variety, was movement oriented and less restrictive, and was outdoors.

5. From a genetic standpoint, ADHD is known to be highly heritable and familial, and several members of Tom’s immediate and extended family also had documented ADHD.

6. The diagnostic interview with both Tom and his mother supported an early-appearing, chronic, and pervasive pattern of impairment in attention and self-control separate from his more discrete learningheading problems. There was also ample evidence that these symptoms were continuing to cause significant current impairment in his adult life in school and work domains.

7. My diagnostic interview carefully ruled out other possible explanations for his symptoms before concluding ADHD was an appropriate diagnosis. He denied significant problems with depression, anxiety, substance abuse, mania, or psychosis, and no environmental or situational stressor appeared to better account for his problems.

8. A Ritalin trial produced a dramatically posi- tive response. He was more focused, less restless, and able to sustain his effort and study product- ively for longer periods, and his grades improved significantly while on the medication. Moreover, his parents and girlfriend validated and were aston- ished to see the vast improvements in his self- control, follow-through, ability to listen and not interrupt, and overall behavior.

9. In short, although I thought the LD prob- lems were responsible for the lion’s share of his academic problems, I believed that ADHD was also contributing, and the combination of the two made school a particularly difficult and frustrating experience for Tom.

later SchooVPsychiatricHistory

At the time he saw me, Tom was a third-year law student and was planning to request the accommo-

Kevin Murphy

dations of extended time and the use of a word processor on his upcoming Bar exam. In addition to the objective records already described, he was able to produce documentation of his SAT scores (340 verbal, 390 math the first time, and 410 verbal, 350 math the second time, both with extended time), class rank in high school (135 out of 256), undergraduate transcripts (2.3 GPA and verifica- tion he had received services through the Students with Disabilities Office), and written verification that he had been granted accommodations in past educational and testing environments. We also gathered his prior intellectual assessment results, which consistently showed him to be functioning in the above-average range of intelligence (most recent WAIS-R results were Verbal IQ 119, Per- formance IQ 112, Full Scale IQ 118). It was quite obvious that Tom was much brighter and had more ability than his rather mediocre paper trail would suggest. He described his struggles in college and law school and the perseverance and methods he employed to work around his weaknesses. He continued to seek tutoring and a proofreader, maximized his use of technology (word processor, spell-check, Palm Pilot), and got to know all of his professors, who ended up respecting his impressive strengths, his work ethic, and his resilience.

Personal Qualities

Another aspect of his history that played an important role in his ability to cope so successfully was his vibrant personality and can-do attitude. It was quite clear from comments on his school records that teachers recognized his many strengths. He was viewed as intelligent, upbeat, articulate, and ambitious. He was also very good- looking, likable, and “politically astute,” which made teachers more inclined to cut him some slack and overlook his weaknesses. Tom told me he felt that having to work so hard to overcome his challenges would prepare him to compete effec- tively in the professional world. His motivation,

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warded copies of Tom’s original school records and past evaluation reports (which should have been sent in the first place) along with the following letter to the Dean of his Law school:

Dear Dean Jones:

The purpose of this letter is to advocate for Mr. Tom and request that you grant his request for accommoda- tions on his upcoming Bar Exam. He is requesting both a computer word processor and extended time. Tom informed me recently that his previous request for these accommodations had been denied. I would like to offer the following documentation to substantiate his diag- noses and provide information to demonstrate that his request is both legitimate and reasonable.

I evaluated Tom on (date of service) and found that he met criteria for Adult Attention Deficit Hyperactivity Disorder (314.01). He also has a longstanding learning disability (dyslexia), which is well documented and has resulted in significant academic struggles for him. He began receiving resource room and special education services in second grade and continued them throughout his school history. He has a history of significant weak- nesses in reading, auditory processing, spelling, foreign languages, handwriting, and algebra. Tom has been granted special accommodations, including extended time and use of a computer throughout his high school, college, and law school curriculum and has come to rely on this as an essential support for him to demonstrate his true knowledge. I have included copies of all his prior evaluations and test reports to substantiate his long- standing history of both LD and ADHD symptomatol- ogy and impairment. To deny him this request now, after he has become accustomed to using the computer and having extra time, would be unfairly penalizing him, in my opinion.

Tom informed me that the consultant that assists you in determining eligibility for special accommodations wanted to see additional documentation that better sub- stantiated an early onset of symptoms, ongoing func- tional impairment stemming from his disability, and current impairment. The enclosed documents should be more than sufficient and Tom regrets that he did not include them in his original request for accommodations. I am aware of the high “burden of proof” necessary to substantiate both a diagnosis and a disability. I am also confident that this documentation will clearly demon- strate that he has the necessary history, evidence of chronic and pervasive functional impairment, and a his- tory of prior treatment/accommodations to justify that he is substantially limited in the major life activity of learning.

intense desire to succeed, and upbeat attitude allowed him to truly believe he could become a successful lawyer in spite of his problems. He did not dwell on his areas of weakness or use them as excuses-he found a way to work around them and spent more time developing his strengths. He did not overreact to setbacks. Instead, he learned from them and developed concrete plans to offset them. I could not help being impressed with his character and the way he approached his problems. In short, Tom was always willing to put the necessary time and effort in to do the best he possibly could and refused to let obstacles derail him.

Initial Request for Accommodations on the Bar Exam

Tom continued to receive accommodations for extra time and the use of technological supports throughout law school. Although it was an on- going struggle, he made it through. When it came time for the Bar Exam, he simply completed the rather brief application for test accommodations (requesting extra time, use of a word processor and spell check) and assumed they would be granted without question. He assumed wrong. His request for accommodations was denied because he had failed to provide adequate objective documen- tation that substantiated his diagnoses, and he had not demonstrated that he was substantially limited in a major life activity compared to the average person in the population. Tom was understandably shocked and angry and immediately asked me to advocate for him because he knew it would be near impossible for him to pass without the accommo- dations he had come to rely on.

I asked him to gather all his prior records to- gether and explained the high “burden of proof” required to be considered disabled under the law and how special education laws like IDEA differed from antidiscrimination laws like the ADA. I for-

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I understand that on the face of it Tom does not come across as someonewith significantlearning disabilitiesor ADHD. He is intelligent, verbally skilled, makes a nice presentation, and has no outward or obvious signs of any disabilities. However, his problems are real and well documented and continue to interfere in his functioning. He has done an extraordinary job of coping with his challenges and is an excellent role model for others who are struggling to overcome similar problems. He deserves a lot of credit for his perseverance and willingness to face these kinds of academic struggles,which, to say the least, do not come easy for him.

Tom will need to use computer technology and employ all of his compensatory strategies when he be- comes a lawyer. He has always been willing to do what- ever it takes to succeed. I urge you reconsider your previous decision on the basis of the strength of the enclosed documentation. Thank you for your time and consideration of this matter.

Sincerely,
Kevin Murphy, Ph.D.
Chief, Adult ADHD Clinic
University of Massachusetts Medical Center

Outcome

After submitting the supporting documentation and letter, Tom was granted his requested accommo- dations and passed the Bar Exam on his first attempt. He is currently a successful attorney in the invest- ment banking industry in a large northeastern city.

Keys to Appropriate Documentation and Effective Advocacy

What were the reasons Tom was granted accom- modations? The following points are crucial to keep in mind when evaluating the adequacy of documen- tation for ADA level accommodations requests.

1. He provided a compelling paper trail docu- menting ADHD and LD symptomatology from early on in childhood that had continued to cause significant impairment in his life presently. Hence,

Kevin Murphy

he adequately substantiated a childhood onset and current impairment with hard data.

2. His documentation showed that the DSM-IV criteria for ADHD and LD had been applied and provided a sound rationale for the diagnostic con- clusions supported by data from multiple sources (diagnostic interviews, testing, objective historical records, parent input)-not merely self-report.

3. He provided data to indicate he had been undergoing standard treatments for LD and even- tually ADHD since childhood (tutors, academic and test accommodations, behavioral strategies, special education, resource room assistance, and medication).

4. His documentation offered sufficient data to validate that he experienced developmentally deviant and clinically signlJcant impairment arising from his learning problems and ADHD. For example, he had severe problems learning to read, was recommended to be held back in second grade, required tutors throughout his school history, failed several classes and consistently struggled in school despite above- averageintelligence, and had great difficultyregulat- ing his behavior as evidenced by the pervasive tea- cher comments on his report cards.

5. There was a logical connection between the nature of his impairment and the accommodations he was requesting. All too often, a costly mistake diagnosticians make is to infer that if their client has a diagnosis of ADHD (or LD), then this alone should automatically entitle them to any and all possible accommodations regardless of whether the accommodation has any relevance to their particu- lar history of functional impairment. This is not true. A mere diagnostic label is insufficient to jus- tify accommodations. Clinicians must remember that accommodation requests need to be tailored to each individual’s unique set of circumstances, need to logically flow from the history of functional impairment, and need to be supported by the his- tory of academic struggles-ideally by objective records rather than only self-report.

6. He provided compelling evidence to indicate that extended time and use of a word processor were

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that ADHD (or LD) was the appropriate diagno- sis. This is another common error of omission. Clinicians should always indicate they have con- sidered and ruled out the range of other possible reasons for the symptom picture, such as mood and anxiety disorders, substance abuse, family/marital problems, and a situational/environmental stres- sor. Failure to do this leaves doubt as to what may be causing the impairment-since all of these possibilities can result in ADHD-like symptoms.

Conclusion

The area of academidtest accommodations and ADHDisindireneedofmorehigh-qualityresearch. Critical questions, such as how much extra time is appropriate for various disabilities, how various dis- abilities impact people in testing situations, and what types of accommodations are appropriate for whom, need to be further explored before we can draw any data-based conclusions on these issues. In the meantime, if clinicians wish to optimize their advocacy efforts for students with ADHD or LD, it is strongly recommended they adhere to the prin- ciples suggested here and build a solid case for the diagnosis as well as providing a defensible rationale for the requested accommodations. *

*For a more detailed discussion of the ADA and test accom- modations/documentation issues, including a sample report, see Gordon and Murphy (1998) and the additional references at the end of this chapter.

REFERENCES

Barkley, R. A,, & Murphy, K. R. (1993). Guidelines for a written clinical report concerning ADHD adults. The ADHD Report, l(5).

Gordon, M., Barkley, R. A,, & Murphy, K. (1997). ADHD on trial. The ADHD Report, 5(4), 1-4.

Gordon, M., & Murphy, K. R. (1998).Attention deficit hyper- activity disorder (ADHD). In M. Gordon & S. Keiser (Eds.),

appropriate accommodations to ease the impact of his disabilities and that he had benefited from them historically. The data supplied indicated that given the nature of his impairment, he would be at a dis- tinct disadvantage without those accommodations. Indeed, his use of those accommodations was well documented for many years, and he had come to rely on them to demonstrate his knowledge. The quality of his earlier records showed that denying those accommodations in his case would have been un- fairly penalizing him on the basis of his disabilities.

7. He provided data from multiple sources (self and parent interview, prior assessment reports, ob- jective school records, past standardized testing scores, narratives from past treatment profession- als and tutors) that demonstrated concurrent val- idation regarding the nature and degree of his problems. His diagnosticians did not simply recite a barrage of test scores as if some testing algorithm alone could substantiate a disability. This is an- other common error that many clinicians make. They oftentimes rely almost exclusively on or over- emphasize testing results as the basis for an ADHD diagnosis-instead of gathering a comprehensive history, as was done here. There is no test or bat- tery of tests that can reliably diagnose ADHD. It is critical to build a case based on documenting long- standing patterns of inadequate adjustment and not simply pointing out relative weaknesses on selected subtests as if this is proof positive of ADHD. And bear in mind that someone with su- perior overall intelligence whose worst scores on a testing battery are still average would likely not be considered disabled, because they would not be viewed as sufficiently deviant from the average person. In other words, an intraindividual discrep- ancy alone is not adequate to substantiate a dis- ability; there must be associated evidence that the

person’s functional ability is impaired to a signifi- cantly greater degree than most people in the gen- eral population.

8. His current and prior diagnosticians docu- mented that they had ruled out other possible explanations for his problems before concluding

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Kevin Murphy

Accommodations in higher education under the Americans with Disabilities Act (ADA): A no-nonsense guide for clin- icians, educators, administrators, and lawyers (pp. 98-129). New York: Guilford Press.

Gordon, M., & Murphy, K. R., & Keiser, S. (1998). Attention deficit hyperactivity disorder (ADHD) and test accommoda- tions. The Bar Examiner, 67(4), 26-36.

Murphy, K. R.,& Barkley,R.A. (1996).PrevalenceofDSM-IV symptoms of ADHD in adult licensed drivers: Implications for clinical diagnosis. Journal of Attention Disorders, 1(3), 147-1 61.

Murphy, K. R., &Gordon, M. (1996).ADHD as a basis for test accommodations: A primer for clinicians. The ADHD Report, 4(6), 10-11.

Murphy, K. R., & Gordon, M. (1998). Assessment of adults with ADHD. In R. A. Barkley (Ed.), Attention de$cit hyper-

activity disorder: A handbook for diagnosis and treatment

(rev. ed., pp. 345-369). New York: Guilford Press. Murphy, K. R., Gordon, M., & Barkley, R. A. (2000). To what extent are ADHD symptoms common? A reanalysis of standardization data from a DSM-IV checklist. The ADHD

Report, 8(3), 1-5.
Albertsons v. Kirkingburg, 527 U.S. 555, 119 S. Ct. 2162, 144

L.Ed.2d 518 (U.S. 1999).
Murphy v. United Parcel Service, Inc., 527 U.S. 516, 119 S. Ct.

2133, 144 L.Ed.2d 484 (U.S. 1999).
Sutton v. UnitedAirlines, Inc., 527 U.S. 471, 119 S.Ct. 2139, 144

L.Ed.2d 450 (U.S. 1999).
Gonzalez v. National Board of Medical Examiners, No. 99-193 1,

(6th Cir.) (2000).
Price v. National Board of Medical Examiners, 966 F. Supp. 419,

425 (S.D. W.Va. 1997).

The Clinician’s Role in theTreatment of ADHD

OVERVIEW

In this chapter I will describe the gradual evolu- tion I have undergone as a clinician, over the past dozen years, as I increasingly specialized in treat- ing adults with attention deficit hyperactivity disorder. This evolution was influenced by my ob- servation that many of the therapeutic approaches in which I had been trained were much less effec- tive in working with adults with ADHD. My orien- tation shifted from a focus on “psychological” issues to a focus on “neuropsychological” issues. It became clear that some of the approaches used in cognitive rehabilitation with individuals suffer- ing from much greater neurological challenges could be appropriately adapted for use with adults with ADHD. At the same time, it became evident to me that some of the structures and supports that were helpful for children with A D H D could be modified for adults by shifting emphasis from educational issues to vocational issues. Be- cause we are treating adults with difficulties in practical, everyday functioning, we need to de- velop specific skill sets, as clinicians, for which we have received little or no prior training. After

Clinician’sGuideto Adult ADHD:
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outlining the theoretical underpinnings of the therapeutic approach that I have gradually de- veloped, I will illustrate its practical applica- tions through the discussion of several clinical cases.

Like many other clinicians who currently treat adults with ADHD, I worked for many years as an eclectic but traditionally trained psychotherapist. I used a combination of approaches, including psy- chodynamic, insight-oriented techniques, cognitive- behavioral therapy, and family systems theory, among others. I was taught, as most of us were, to offer no directives or advice and to allow the client to set the pace and select the focus for each session. My role was supportive, passive, interpret- ive, and sometimes challenging of the client’s atti- tude or beliefs, but never directive or prescriptive. The common belief among most schools of psycho- therapy was that there was some neurosis, inner conflict, or learned attitude that underlay dysfunc- tion in daily life. Once this psychological determin- ant was addressed, the individual would quite naturally begin to behave in a more constructive, “healthy” manner in his or her daily life and rela- tionships.

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I was taught to believe that the individual would take up healthier modes of livingwhen “ready” and not before. My role was to help the client achieve this state of “readiness,” not to suggest, direct, or influence the mundane details of daily life. In fact, therapists generally relegated a focus on “practical” issues to other, less highly trained professio- nals-counselors, career consultants, and the like. Our focus was on “deeper,” more important “psy- chological” issues, disdaining a superficial “envir- onmental cure.” Changes in partners, places of employment, or regions of the country were con- sidered escapist efforts that were doomed to failure because “psychological” problems would follow the client wherever we went.

At the same time that I worked with adults using these widely espoused methods, I began to work with an increasing number of children with ADHD. Following the passage of laws mandating that services be provided for children with special needs from ages 2 to 21, the number of parents seeking diagnosis and treatment of ADHD for their children increased dramatically. Finally, the schools were required to provide services and sup- port. There was suddenly a strong incentive to seek an ADHD diagnosis in order that children could benefit from the programs and services being de- veloped.

In my work with parents and children with A D H D , I played a variety of roles: diagnostician (administering psychological and psychoeduca- tional testing), therapist (focusing on social and interpersonal issues of children with ADHD), family therapist (working with parents and chil- dren to develop more workable daily routines and problem-solving strategies), and educational con- sultant (attending school meetings with parents as complex individual educational plans (IEP’s) were developed to meet the needs of each individ- ual student. I interfaced with tutors, neurologists, pediatricians, child psychiatrists, educational spe- cialists, sensory integration specialists, vision spe- cialists, and any other professionals whose specialty touched on some condition commonly associated

Kathleen G. Nadeau

with ADHD. These children had complex needs that could be met only through a variety of ser- vices. My role evolved beyond therapist to treat- ment coordinator, developing and coordinating wrap-around treatment programs for these chil- dren.

A few short years later, children whom I had first encountered at age 8 or 9 were in high school, approaching college. It became essential that I work with such students and their families to iden- tify colleges that could provide good support ser- vices. For those who weren’t attending college, my focus was on helping them to make good choices of vocational training or to find “ADHD-friendly” entry-level employment. For those high school stu- dents heading to college, it became evident that these young adults needed much guidance to make an appropriate choice of a college major that was compatible with their strengths and interests. Personality testing, interest testing, and career gui- dance were essential. However, it was my experi- ence that when these students were referred to career counselors or career centers, they often could not find anyone experienced in the special needs and concerns of young adults with ADHD. Career testing and guidance became, by necessity, an important part of the growing set of therapeutic skills that I found necessary in order to effectively treat adolescents and young adults.

Meanwhile, parents of children with ADHD self-identified and sought treatment for adult ADHD issues. Many of these parents struggled with adult versions of the very same sorts of chal- lenges that befell their children: self-esteem issues and relationship difficulties, impulse control, diffi- culty developing and maintaining habits, disorgan- ization and forgetfulness, and difficulty reaching their potential in the world of work. Paralleling the school challenges faced by children, adults faced similar challenges in the workplace: difficul- ties with deadlines and with completing long-term projects, difficulties expressing themselves suc- cinctly either verbally or in writing, problems with details and paperwork. And because continuing

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forgetting as resistance to treatment, never suggest- ing to the client techniques that can help develop better on-time habits or reminder systems. Psycho- therapy with adults with ADHD is ineffectivewhen it ignores the need for structure in the therapy ses- sion; worse, though, is the potentially destructive psychotherapy that blames the client, attributing his neurologically based patterns to dark, negative psychological forces.

A MULTI-LEVELAPPROACHINTREATING ADHD IN ADULTS

The challenge for the psychotherapist is to sort through the layers of personality traits, of psychic conflicts, and of neurologically based patterns and to approach each of these in ways that can effec- tively address them. The effective psychotherapist of individuals with ADHD needs to take a broad perspective rather than use a single theoretical lens through which he or she interprets all behaviors.

In working with an adult with ADHD, it is essential never to lose sight of the to need treat the client on multiple levels simultaneously. ADHD is a condition that has a primary neurological basis with secondary psychological features, and exists, very commonly, alongside complicating coexisting psychiatric disorders that must be addressed as well if treatment for ADHD is to be effective.

Neurocognitive Psychotherapy

First, the therapist must always remember that ADHDisprimarilyaneurobiologicalconditionthat affects behavior and emotions. To address the neurobiological aspect of ADHD, we can borrow very appropriately from cognitive rehabilitation models, using those theoretical underpinnings to design a treatment program. Typically, cognitive rehabilitation treatment models approach the re- habilitation of a neurologically impaired individual via a multidimensional method:

education is a necessity for many of us as our careers evolve or change, adults with ADHD must often face daunting educational challenges that more directly parallel the challenges that chil- dren with ADHD must meet in the classroom. They, too, needed assistance in learning how to manage their ADHD patterns on a daily basis. But unlike their children, they did not have a parent at home to help them implement and consistently practice the new patterns they were attempting to develop.

Increasingly, adults who had been unable to find a therapist experienced in diagnosing and treating adults with ADHD contacted me. Often they had sought treatment from a psychiatrist or psycholo- gist whose response was that he or she “didn’t believe in” adult ADHD. Unfortunately, ten years later such a response is still not uncommon, but even those who acknowledge ADHD in adults are often prone to misdiagnose ADHD as anxiety, depression, or bipolar disorder, misinterpreting ADHD symptoms. Such diagnoses of depression and/or anxiety may be not incorrect but, rather, incomplete, because they overlook underlying or comorbid ADHD.

Even when the diagnosis of ADHD is made cor- rectly, the treatment approaches, aside from the pre- scription of stimulant medication, are often ineffective, and sometimes potentially destructive. Many psychotherapists, it seems, have simply trans- ferred their generic bag of psychotherapeutic tricks to the treatment of adults with ADHD, making psychodynamic interpretations, approaching the psychotherapy session in an unstructured and non- directivefashion, and focusingprimarily on improv- ing self-understanding and self-esteem.In the worst cases, psychotherapists interpret ADHD-driven be- haviors from a psychological rather than neurocog- nitive perspective. Viewed through psychological lenses, lateness is an expression of passive aggres- sion, impulsivity is a function of immaturity, and compulsive talking and drivenness are evidence of bipolar disorder. A psychodynamically oriented clinician may persist in interpreting lateness and/or

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0 Improving cognitive function
0 Developing internal and external

compensatory strategies
0 Restructuring the physical and social

environment to maximize functioning

Improving Cognitive Function

In treating ADHD, the most powerful and im- mediate intervention to improve cognitive function is the use of psychostimulant medication. Im- proved cognitive functioning can also be supported, secondarily, through improved sleep patterns, regu- lar exercise, improved nutrition, and reduced stress. The clinician should consider all of these strategies to be appropriately within her or his domain, en- gaging the collaboration of other professionals as needed.

Developing Internal and External Compensatory Strategies

The second component of cognitive rehabilita- tion is to develop internal and external compensa- tory strategies. Teaching compensatory strategies is highly useful in working with an adult with ADHD and should appropriately be a major focus of ther- apy. In my therapy with patients, I refer to such strategies under the umbrella of “learning how to take charge ofADHD.”

Restructuring the physical and Social Environment

The third prong of this cognitive rehabilitation approach is that of restructuring the physical and social environment to maximize functioning. In my work with adults, I speak about this environmental restructuring in terms of creating an ADHD-friendly environment.Socialrestructuring involveseducating family members and significant others, as well as making proactive choices to live among, socialize with, and work among individuals who are more aware of the individual’s strengths and less critical

Kathleen G. Nadeau

or intolerant of his A D H D patterns. Physical re- structuring involves changing aspects of the client’s physical environment to minimize the challenges of ADHD. This might entail changing to a less stress- ful job, moving to shorten a stressful commute, moving from a single-familyhome to a townhouse to lessen the stressful maintenance demands of a larger home, or organizing and uncluttering the home to promote more efficient, orderly daily rou- tines for the family.

We commonly use all of these techniques when working with children with ADHD. We work, through coaching, tutoring, teaching therapist and parent support, to enhance the child’s execu- tive functions of planning, self-monitoring, remem- bering, and following through on homework and extracurricular projects. We help the child to begin to develop compensatory strategies: making lists, writing down reminders, using day planners to record homework assignments and activities. And we actively work to make his or her social and physical environments more ADHD friendly through careful selection of school, of classroom teacher, of playmates, and of extracurricular activ- ities. Most therapists can transfer these approaches fairly easily to 18- or 20-year-olds. But with older adults, we may forget the neurobiological under- pinnings of the challenges they face and assume that they are, or should be, capable of doing such things for themselves, without the least guidance or suggestion from the therapist!

Addressing Secondary Psychological Issues

In addition to addressing cognitive functioning, it is critical to address the secondary emotional symptoms of ADHD. By the time an individual has struggled with ADHD for many years, there is a secondary but very significant set of issues, including low self-esteem, demoralization, a sense of shame and self-blame, as well as anxiety and

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functioning individuals (although this may come at a great cost), as well as among very dysfunctional individuals who have struggled with unemployment, substance abuse, and repeated encounters with the judicial system. Because the treatment of adult ADHDisinitsinfancy,themajority ofthoseseeking treatment fall into the more educated, higher-func- tioning end of the spectrum. There is enormous need, however, to treat the great numbers of adults with ADHD who are in prison, who are on unemploy- ment roles, or who are chemically dependent. A broad array of clinical skills and extensive training and experience across a spectrum of disorders is required to treat this disorder that is so commonly embedded in a spectrum of related disorders.

BASIC ISSUES IN TREATING ADULTS WITH ADHD

Structuring the Psychotherapy Session for Adults with ADHD

It may be helpful to think of the therapy session as a microcosm of the issues that are faced in the days, weeks, and months in the life of an adult with ADHD. Just as structure, compensatory strategies, and reminders are needed in daily life, they are also needed within the therapy session. The therapist, to be most effective, needs to have her “therapist’s ears” attuned to unspoken feelingsand unexpressed issues, guiding the client to deal with important issues that may not be in the forefront of the client’s mindashecomestothesession.Butatthesametime, the therapist should always be aware of the difficul- ties experienced through lack of structure. Unlike with other sorts ofclients, it is rarelymost productive toallowtheclienttorambleorfree-associate.Infact, rambling associations are exactly what the client needs to combat in order to remain effectively focused on the conversation or activity at hand!

Memory difficulties are commonly reported in adults with ADHD. There may be no real sense

depression that result from the chronic stress of living with ADHD.

Many adults have engaged in more traditional psychotherapy for years. They have known that “something was wrong,” but neither they nor their psychotherapist knew that the “something” was related to ADHD. Often, such traditional psy- chotherapy has been helpful in dealing with de- structive early childhood experiences, trauma, or depression. However, even when such issues have been dealt with effectively, these adults are left with a feeling of being out of control in their daily lives, overwhelmed by issues that others deal with more evenly. In the worst cases, adults seek treatment for A D H D having been damaged by previous psycho- therapy. Such individuals, prone to feelings of shame and self-blame, have had these feelings strengthened through the destructive process of having their neurologically driven behaviors inter- preted psychologically. The psychotherapist has, in effect, endorsed their self-blame, implying that they could stop their disorganization, lateness, forget- fulness, and general underfunctioning if they effec- tively addressed their psychological issues.

Treating Comorbid Conditions

To complicate the situation further, ADHD is typically one of a cluster of issues that must all be addressed in order for treatment to be effective. Individuals with ADHD frequently suffer from high-incidence conditions such as learning dis- abilities, anxiety, and depression, as well as low- incidence conditions such as obsessive-compulsive disorder, bipolar disorder, posttraumatic stress dis- order, chemical dependencies, eating disorders, and Tourette’s syndrome, among others. For a certain subset of adults with ADHD, comorbid childhood oppositional defiant disorder has evolved into a conduct disorder and finally into an antisocial personality disorder.

ADHD exists along a continuum from mild to severe and can be found in highly intelligent, high-

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of continuity from session to session without added structure from the therapist. Audiotaping sessions can be extremely helpful. Clients may tape their session and then review it repeatedly while driving their car during the week. If taping is not done, notetaking is essential. Clients should be encour- aged to purchase a spiral notebook dedicated to their therapy sessions, in which they should write key issues that are discussed and issues that occur to them during the week that they want to bring up in the subsequent session, and in which they record “homework assignments.” It can even be helpful to have a supply of such notebooks on hand to provide to new clients. It is also helpful to review homework assignments at the beginning of the session. Was the assignment accomplished? If not, why not? A brief review of medication, its effectiveness, and its side effects is also helpful. It’s often very useful for the therapist to be in periodic contact with the prescribing physician to share observations regarding medication. Then the therapist should ask the client what issues he or she would like to address during the session. If both therapist and client write these topics down, the session becomes more structured. At the end of the session, a brief review of topics and strategies that have been discussed, followed by a new homework assignment, sends the client on his or her way with a focused approach for the week ahead.

Collaboratingwith an ADHD Coach

Distractibility, poor follow-through, and faulty memory sometimes combine to render weekly ther- apy sessions only moderately effective. With such clients, I sometimes engage the support of a trained A D H D coach who can contact the client for brief phone sessions during the week to reinforce the strategies we have been working on. This can be especially helpful when a client with A D H D is

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engaged in a complex, multistep task, such as working on a dissertation, applying to college or graduate school, or engaging in a job search. Thrice-weekly, and at times even daily, contact with a coach can help keep them moving forward, taking some step every day to move them closer to accomplishing their goal. It is important to find a coach who is welltrained and experienced in working with adults with ADHD and who has a clear sense of the appropriate boundaries between coaching and psychotherapy. Since most coaching takes place via telephone and/or e-mail, it is not necessary that the coach live in the same area as the therapist and client. Brief communications between the therapist and coach will help to coordinate their efforts.

Use of ProfessionalOrganizers and Time Management Technologies

The single most common complaint of adults with ADHD has to do with disorganization, in- cluding time management, household manage- ment, and money management. It is extremely helpful for therapists who specialize in treating adults with ADHD to remain abreast of new technologies and tools that can aid their clients in becoming better organized, such as computer soft- ware, electronic reminders, and time management systems. Engaging a professional organizer when a client expresses feeling completely overwhelmed by disorganization in the home, in paperwork, or at the office can often be extremely useful. A profes- sional organizer can assist the client in digging out from under chronic chaos. Then the therapist and/ or coach can assist the client to develop better habits that can help maintain better organization. Many adults with ADHD find it so difficult to remain organized that they may need to budget for biannual visits from a professional organizer as one of their A D H D coping mechanisms.

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Money management-the ability to track expenditures,to accuratelyassesswhether one can afford new expenditures, to control impulsive spending, to keep track of and pay bills in a timely manner, to maintain records necessary to file accurate tax returns Relationsh@problems,which are often related to poor communication patterns, including monologuing, interrupting, becoming distracted during conversation, not knowing “when to stop,” and emotional overreactions.

Workplaceproblems, such as feeling highly stressed at work, feelingunable to successfully meet some of the demands of one’s current job, questioning whether one has made an appropriate career choice in view of the challenges of A D H D

Childhood ADHD specialistswouldn’t dream of saying that they couldn’t deal with daily behavioral issues or school-related concerns for a child. Yet as adultspecialists,wehaven’tyetmasteredtheequiva- lent skills to help adults with daily life management and workplace concerns. As children with ADHD matureandleavetheirschoolyearsbehind,thework- place, rather than the classroom, becomes the area of greatest challenge. The things we do at work are comparable in many ways to schoolwork. At work, most of us must read, write, make calculations, or- ganize and carry out projects, meet deadlines, learn new information, and pay attention during meetings andlectures.ThechallengesthatadultswithADHD faceintheworkplace deservethesameattentionthat has been focused on the academic functioning of children and adolescents with ADHD.

TREATING ADHD ACROSS THE ADULT LIFE SPAN

Transition to Independence in Young Adulthood

Let’s consider the types of issues and problems that must typically be addressed as young adults

Exnanded Clinical Skills Called For in Treating ADHD in Adults

Psychotherapists who seek to become a specialist in treating adults with ADHD need to develop a broad skill base that allows them to assist with the “neurocognitive” issues as well as the more familiar psychological issues of anxiety, depression, low self- esteem, and relationship problems. Although adults with ADHD come with an enormous variety of abil- ities, family backgrounds, and life circumstances, there seems to be a core set of issues with which most of these adults typically struggle, including problems with daily life management, time manage- ment, decisionmaking, and workplace functioning.

Self-esteem issues may plague adults with ADHD, especiallywomen, throughout their lifetime. Even though some may have reached highlevelsofachievement,adultswithADHD often feel they have not lived up to their potential, that they are “imposters” struggling to hide inadequacies from family and coworkers,andmaycharacterizethemselvesas lazy, disorganized, immature, and unreliable.

Underdeveloped life management skills, or a sense that the management of daily life causes great stress and often a feeling of being “out of control,” include the following.

Thing management-the ordering and maintenanceofthehouseholdandtheobjectsit contains (e.g., filing papers, keeping personal objects in remembered retrievable locations) Timemanagement-the ability to be on time, to remain appropriately aware of the passage of time, and to predict accurately how much time should be allocated to specificdaily tasks. To-do management (prospective

memory)-the ability to keep in mind, or to recall at the appropriate time, specificacts that should be undertaken at some future time (e.g., remembering to take necessary papers to school or the office, running errands at specific points en route, keeping appointments)

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with ADHD begin to make the transition to inde- pendent adult living.

First, consider approaches that have proven effective for children and how they might be appro- priately applied as children transition to adulthood. Sam Goldstein and Michael Goldstein write in the Preface to their recent, comprehensive text, Munug- ing Attention Deficit Hyperactivity Disorder in Chil- dren (1998) that “successful treatment of ADHD requires a balance between symptom relief and building in protective factors that enhance resili- ence, defined as the capacity to recover from stress and lead children to successful transition into adulthood” (p. xv). The protective factors to which the Goldsteins refer include those related to (1) school, (2) friends, and (3) family. In working with young adults, all three of these factors remain relevant. In addition, a fourth set of protective factors, relating to the workplace, become critical.

Although for many individuals with ADHD in adulthood there is symptom reduction and the de- velopment of coping strategies, adult life also brings a great increase in demands on the individ- ual for judgment, organization, self-control, and long- range planning. The very psychological traits that one normally associates with maturity-the ability to delay immediate gratification in order to achieve long-term benefit, the ability to act based on reason rather than on immediate emotional impulse, the ability to make plans and to carry through on those plans-are all among the most challenging traits for individuals with ADHD.

When children with ADHD become teens and then young adults, many of the protective factors that have supported them will gradually, or even suddenly, fall away. Their lives are less structured by parents and teachers. There is no one available to make sure that medication is taken as pre- scribed, or taken at all. The transition from adoles- cence to independent adult living is fraught with challenges that require knowledge that has not yet been acquired and a planning ability that is inad- equately developed. They must suddenly be able to manage money, successfully make job applications,

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make choices as to career direction, sign leases, apply for automobile insurance, file income tax returns, and keep up with the routine maintenance activities of daily life-getting adequate sleep, pro- viding themselves with regular meals and clean clothes, and maintaining their living space. As one mother of an adolescent boy with ADHD voiced, with reason for concern, “He’s not able to make his bed. How’s he going to make a life?”

As they struggle to cope with the lack of struc- ture in their lives, young adults with A D H D may make decisions that only increase their sense of being overwhelmed. For example, one young man found himself uninterested in the limited jobs avail- able to him as a high school graduate. He reasoned that if he purchased an expensive automobile the large monthly car payment would motivate him to get up in the morning and maintain regular em- ployment. Instead, as might have been predicted, this decision only led to financial overextension that caused him to break the lease on his apart- ment, whose rent payments he could no longer afford. Soon he was sleeping on the couch of a friend, sinking into depression as his barely estab- lished independence crumbled.

As psychotherapists, how can we best help young adults with ADHD as they struggle to make the successful transition to independent adult life? Somehow, we need to help the young adult with ADHDseek,develop,orcreatethesamesortsofpro- tective factors that support children with ADHD. These protective factors include things such as an environment that promotes structure and predict- ability, a work or school environment that is sup- portive and that reasonably accommodates ADHD traits, and the social support of friends and family who accept the negative and appreciate the positive in them.

ADHD-Friendly lifestyle

One overarching concept essential in the treat- ment of all adults with ADHD is that of an

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adult better understand his attractions to alcohol, marijuana, excessive caffeine, carbohydrates, cigar- ettes, or other substances, and can perhaps minim- ize patterns that can, if left untreated, rapidly lead to very destructive addictions and dependencies.

Increased Choices Beyond High School

Many young adults with ADHD havejust passed through some of the most ADHD-unfriendly years of their life as they exited high school and entered their young adult years. High school is often a de- moralizing experience for teens with ADHD. Sud- denly they are bombarded with increasing academic demands. Their native intelligence is often no longer enough to support them as reading and writing as- signments lengthen in high school. They can’t get by just by paying occasional attention in class and hur- riedly scribbling homework assignments on the bus. During high school years there is relatively little choice available to students with ADHD. They must conform to the standard curriculum and must sit and listen for many hours every day. Once they graduate from high school, however, an enor- mous range of choices opens up. The clinician working with young adults with ADHD should take an active role to make them aware of the many choices available and should help them care- fully consider the choices they make in view of cre- ating an ADHD-friendly life.

Decreasing Structure and Support

If they have been fortunate, young adults with ADHD have had parents who worked to provide them with an ADHD-friendly environment as they have been growing up-an environment that is structured and predictable, with regular routines that support the completion of daily activities

ADHD-friendly lifestyle. It is critical that the ther- apist have a clear sense of what factors might consti- tute an ADHD-friendly lifestyle for each client. The therapeutictask,then,istoconveythistoclientsina constructive manner that helps them to identify the “unfriendly” factors in their current lifestyle as well as to identify ways they can make choices and changes to move toward a more ADHD-friendly living environment. This ADHD-friendly lifestyle is built, in part, from the “protective factors” dis- cussedpreviously.Thetherapist andclient,together, must work to identify situations that tend to worsen ADHD patterns: poor sleep patterns, poor nutri- tion, lack of exercise, substance abuse, high stress level, too little or too much stimulation, social rela- tionships that encourage ADHD-unfriendly behav- iors, and career choices that require the client to operate in areas of relative weakness, among others.

ADHD-Informed life Choices

One of the great advantages of seeking treat- ment as a young adult is that the most important defining life choices are still ahead. With the help of therapy, such choices can become informed by the concept of building an ADHD-friendly life. Typic- ally, as a young adult, one has not yet chosen a life partner, has not become a parent, and has not made great commitments of time or money toward any single career or profession. Understanding one- self-one’s strengths, weaknesses, interests, and passions-within the framework of ADHD can help make those choices beneficial ones that can have a positive impact on ADHD.

AppropriateTreatment Rather Than “Self-Medication”

Another important concept to introduce to the young adult with ADHD is the common pattern of self-medication. The therapist can help the young

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necessary for a healthy, productive life. Such pre- dictability has probably eroded as the teens with ADHD have struggled to assert their independence. Now the teens have become young adults and rou- tines may be almost nonexistent, even if they are still living in the family home.

One young man, whom we’ll call Chris, was brought to therapy by his parents as a last-ditch effort before evicting him from their home. He had been a struggling student in high school, but had attended fairly regularly until he was injured in an automobile accident. This injury suddenly elimin- ated normal routines from his life. After a several- month recovery, during which his classmates com- pleted the school year, he chose not to return to school because he would have been required to re- peat his junior year while all of his friends would be seniors. A series of short-lived minimum-wage jobs followed. Chris gradually sank into despondency as he recognized that he had few options without a high school diploma and as his social isolation increased.

Eventually he fell in with a group of other young men whose situations were similar-school drop- outs with marginal employment. They stayed up all night, smoking marijuana and drinking beer, and slept until noon. Frequent arguments with parents occasionally motivated them to make a minimal effort to find employment, and severe conflict with parents led these young men to seek refuge, period- ically, on the basement couch of another friend in the group. As Chris was brought for therapy he was facing a similar eviction notice from his par- ents-go to work, go to school, or get out. In a family session Chris expressed a fear that if he complied with his parents’ demands he would have to shift to a daytime existence and would lose the only emotional support he had-the all-night gatherings with his going-nowhere buddies. “If I do what you want, then I won’t have any friends!”

Chris, like many young adults with ADHD, was highly influenced by his immediate environment. Also, like many with ADHD who have struggled with school and have experienced little success in

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other arenas, he harbored enormous self-doubt and low self-esteem. The challenge in therapy was to help him find a more constructive support system and a plan for the future that encouraged rather than threatened him.

CollaborativeWork with Parents of Young Adults with ADHD

The central challenge facing all parents of young adults with ADHD is how to provide constructive support while at the same time promoting the young adult’s independence. To this end, Chris’ parents were involved in his treatment, both joint and collateral sessions-a pattern that may seem inappropriate if viewed from the perspective of more traditional psychotherapy, where autonomy and confidentiality may take precedence over par- ental concern and involvement, especially for a client 18 years of age. The parents’ sessions focused on gaining a better understanding of their son’s ADHD and how it affected him at this point in his life. The parents had vacillated between enab- ling his self-destructive dependence and angrily demanding that he leave their home and fend for himself. They were aware of the precarious, even dangerous situations that his peers found them- selves in after ejection from the family home, and their fears led them to back away from the angry ultimatums they had repeatedly delivered. Therapy with the parents focused on ways to gradually and systematically support Chris in becoming more functional and independent.

Engaging Community Resources as Protective Factors

Just as clinicians working with young children with A D H D should be aware of community re- sources that can support parents in finding the help they need for their child, the same is true for

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job, and was hired. He began to become friendly with other teens who worked at the mall, whose lives were more structured and functional than his previous group of friends. In therapy he began to talk in a different way about his group of un- employed friends, questioning where their lives were going. Conflict at home with his parents greatly decreased. His parents felt they had a blue- print for helping Chris to become self-sufficient, and they could see the concrete steps that Chris was taking to achieve independence.

Importanceof Short-Term, Reachable Goals

Therapy began to focus on financial manage- ment as Chris began to bring home a regular pay- check. A concrete, highly desired goal for Chris was the purchase of a car. Chris decided to give his parents 25% of each paycheck to save for a down payment. His more mature attitude toward money encouraged his parents, who agreed to help him with a car purchase if he saved a predeter- mined amount of money. Passing the GED three months later led to an enormous sense of achieve- ment. Rather than spending the summer partying and going to the beach with friends, he decided to work full time so that he could purchase a car in September and be ready to enroll in a computer technician class at the local community college.

Continuing Collateral Parent Education

Collateral therapy sessions with parents helped them to better understand the slower maturity rate of their son and assisted them in developing realis- tic expectations. Rather than nagging or exploding, they learned to help Chris solve problems. After six months in therapy Chris was taking responsibility for his own medication and coming to treatment in

young adults; however, the resources generally come from different agencies and educational insti- tutions. Chris was referred to the Department of Rehabilitative Services, where he was encouraged to learn that he was eligible for their services and could receive assistance in a variety of job-training programs-for jobs that paid triple the minimum wage or greater. Chris was also referred to the local community college, where there were many two- year-certificate vocational programs available that might interest him. All he needed to do was to take his GED exam and earn a passing grade.

Tutoring for Young Adults with ADHD

ChrisbegantodiscusstheneedtoearnhisGEDin order to be eligibleforjob training. His parents, also feeling more hopeful, were willing to pay for private tutoring to help Chris prepare for his GED. One-on- one tutoring was strongly suggested due to Chris’ academic anxiety, poorly developed self-discipline, and need for structure. Because Chris had missed most of the last two years of high school and had not been a strong student, it seemed unlikely that he could adequately prepare for the G E D without the support of an individual tutor. Clinicians should be aware that even in the case of much stronger and more accomplished students, it is often helpful, if not mandatory, that the adult with ADHD work indi- vidually with someone to adequately prepare for licensing or professional exams.

Success Breeds Confidence, Which leads to Success

As Chris prepared for the GED, his self-confi- dence began to increase. A friend he had encoun- tered by chance told him of a job in a record store at the nearby mall. To his parents’ surprise he went to the mall without their prodding, applied for the

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the car he had purchased with his parents’ help, and was enrolled in a course of study that gave him an optimistic sense of his ability and his future.

It is readily evident, in examining the role of the therapist in Chris’ treatment, that there are strong parallels between the role of a therapist with a child with ADHD and with a young adult. Parent educa- tion and guidance was a critical component of the treatment, with a focus on helping the parents to understand and help create an ADHD-friendly en- vironment for Chris, an environment that offered structure, emotional support, and short-term incen- tives more motivating than their earlier admonition that Chris was “throwing away his future.” The therapist was active in making referrals to other service providers-a tutor as well as the DRS coun- selor. The tutor was engaged in recognition of Chris’ learning disabilitiesand his need for structured, one- on-one learning. Therapy was focused on:

1. Concrete problem solving (developing an ADHD-friendly environment)

2. Assisting Chris in recognizing the strong influence his environment had on him and the critical importance of changing his social and physical environment (recognizing that his current environment was ADHD unfriendly)

3. Helping him to discover and develop areas of competence (a practical approach to combating the low self-esteem so common in young adults with ADHD)

4. Helping him to recognize the importance of planning and consistency and guiding him in developingmore constructive patterns-saving money, recording appointments, getting himself to appointments on time, and changing sleep patterns so that he could function constructively during the day (developing compensatory strategies as well as habits to promote an ADHD-friendly lifestyle)

A more traditional therapist might have in- volved the parents little, if at all. A more traditional therapist might have focused the therapy on talking

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about his anger and despair rather than on taking actions that would reduce those feelings. A focus in therapy should be on the simple, concrete notion that success breeds success. Chris and his parents were guided to find concrete ways to achieve small degrees of success that would make later successes more likely.

Later sessions would focus on helping Chris develop the skills necessary for successful inde- pendent living as an adult. These skills could be learned in the relatively protective home environ- ment and then later tested in a more challenging, independent living situation. Career-oriented coun- seling would come later as well. It was a great step forward for Chris to have employment at all. In the future, it will become critical to help Chris better understand his interests and abilities as well as his needs for structure and support in a work environ- ment so that he will be more likely to find employ- ment in which he can be successful.

Let’s consider the case of a young adult at the opposite end of the ability spectrum. A young man whom we will call Nick had been in gifted programs throughout his years in public high school, but, des- pite very high intelligence, his grades had only been mediocre. He had strongly resisted taking medica- tion during his high school years and had scraped by, relying on his native ability. Instead of going on to the top colleges that most of his friends would attend, Nick had his choices limited by his academic record. His final selection was a large southern state school, better known for its social and athletic life thanforitsacademics.Hisparentswereskepticalbut had always raisedNick to “make his own decisions,” not realizing that such respect for autonomy might have disastrous consequences. Nick’s family was filled with academic professionals. An older brother had attended an Ivy League college.Nick, according to his parents, was the brightest of all of their chil- dren. They were disappointed in his choices and baffled about how best to help him.

Following a disastrous freshman year that ended with academic probation, Nick was home for the summer, at his parents’ insistence. Nick’s

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him to monitor the stimulant and antidepressant medication that he had agreed to take once more, I also continued to see him with his mother for joint sessions. The focus of the joint sessions was on ac- cessing information about Nick’s behavior from an outside source, but also engaging in A D H D , educa- tion as a family. The typical pattern of delayed ma- turity in many young adults with ADHD, as well as the need for structure and support, was discussed. I told stories about other young adults with ADHD who had failed but who, with critical changes, had later become very successful.I often find this type of storytelling helpful and therapeutic in treating adults with ADHD.

Practical Interventions

In a more practical vein, I suggested that Nick enroll in two courses at the local community col- lege during the summer. I recommended that his family engage the services of a tutor or coach to make sure that Nick did well in those summer courses, enhancing his chances of being able to return to school in the fall. I talked to Nick of the kinds of supports he could access from the student disability support office-priority registration, extended time on tests, note takers in class, and reduced course load. When he had left for college in his freshman year he completely denied his need for treatment or support. After failing, he was somewhat more open to such possibilities. With weekly therapy and biweekly tutoring sessions during the summer, Nick earned two A’s in summer school. In response to this success, and with the help of antidepressants, Nick’s mood lifted and he became better able to engage in more constructive planning for his future.

Nick slowly came to recognize that the com- pletely unstructured living situation at the univer- sity he had attended, as well as his denial of his need for treatment or supports for ADHD, had led to his academic failure. His girlfriend’s decision not to return to the university in the fall probably

preference had been to take a road trip out west with a close friend, but his parents reined him in. They insisted that he seek counseling and treatment over the summer in order to reach a decision about whether to return to the same university in the fall. In addition to academic concerns, Nick showed signs of depression. He had fallen intensely in love with a young woman at school who had a serious struggle with depression herself. Together they had gone in a downward spiral of frequent fighting, making up, sinking into mutual dependency and increasing depression.

Parental Involvement in the Treatment

Nick first came to therapy with his mother, at my request. (Due to work pressures, Nick’s father was not available regularly.) Talking with both of them together, I pieced together the history of his first 18 years. His mother was able to provide the family history and early childhood history that Nick would be unable to provide in detail. As elementary, middle, and high school years were discussed, Nick entered fully into the discussion. The history taking was structured to be the beginning of the therapeutic process for Nick-to help him begin to think of the situations and circumstances in which he had func- tioned well or had functioned poorly over the years.

The immediate assessment was that Nick needed much more structure and supervision-something that went against the grain of his mother’s parenting style and certainly went against the grain of Nick’s late adolescent desires for autonomy and independ- ence. In other words, I wanted Nick and his family to reintroduce more of the “protective factors” under which he had prospered during his elementary school and middle school years. The goal was for Nick to reach and accept this conclusion during the summer and for his parents to understand his need for more hands-on parenting, even at the age of 19. Although I was seeing Nick individually, helping

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helped Nick decide to stay at home and apply as a transfer student to the state university a few miles away. Despite his poor grades as a freshman, the A’s he had earned in summer school convinced the local university to allow him to enroll.

Shifting Focus to longer-Term Goals

Our focus in therapy now shifted to helping Nick think about future career goals. Testing was done to measure academic strengths and weaknesses. Interest testing as well as the Myers-Briggs Inven- tory were completed as well. All the results were considered together, and Nick began to explore various college majors from this more informed viewpoint. The Myers-Briggs not only suggested several possible career directions, but also high- lighted Nick’s extremely extroverted personality. This was interpreted to Nick, and it was suggested that he might enjoy his studies and be more success- ful in them if he organized study groups rather than attempting to hole up in his room to study silently and alone.

More Structure and Practical Problem Solving

Nick’s natural ability to bring people together meant that soon he had organized study groups for each of the four classes in which he was enrolled. His strong needs to socialize were now being met in a much more constructive context. Nick continued to work with his tutorkoach throughout the fall semester and ended with honor roll grades, despite some last-minute paper writing and studying for exams. Nick began to understand his tendencies to procrastinate and to underestimate how long an assignment might take and his need for external structure. Rather than resenting living at home, he began to appreciate the fact that, when he needed

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it, he had a calm, quiet environment in which to rest and study-something that had not existed in his dorm life the previous year.

By the end of Nick’s second semester at home he was in top form. He recognized the benefits that stimulant medication gave him, but felt he needed it only during class and study time. Nick’s depression had lifted, and after a year of taking antidepressants he was directed by his psychiatrist to gradually reduce and finally stop taking the medication. By summer he no longer took the antidepressant medi- cation. During his second year in college, through guidance in therapy Nick had come to identify en- vironmental protection issues as a strong interest. He took a course in environmental scienceand, after speaking with an uncle, began to think of longer- term plans-perhaps law school after college, with a focus on environmental law. Such a career would accommodate his need for extroverted social inter- action and would allow him to focus on an issue in which he had a growing, passionate interest. Rather than the unplanned road trip he had wanted to take the previous summer, Nick, with encouragement in therapy, did some advanced planning and applied for a summer internship with the National Park Service to give him more hands-on experience in an environmental area.

Ready to “Fly”-Not Just leap Out of the Nest

After a year in treatment, Nick felt ready to leave ongoing therapy. He had gained a better respect for thepotentialdestructiveinfluenceoflivinganimpul- sive, unstructured life. He recognized that he thrived withmore structure, both at home andin school, and that he could find a way to combine his extroversion needs and his need to study in a very constructive fashion by forming study groups. Testing and ther- apy had given him a much clearer sense of strengths, weaknesses, and interests. Nick’s family also learned that the “hands-off” approach they had taken in raising his older brother wasn’t, perhaps, the best

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into account. The therapist can be most helpful to the client by regularly focusing on the stress level in the client’s life, problem solving with the client about feasible ways to reduce stress, and teaching the client to consciously building into life some of the “protective factors” that parents typically pro- vide for children with ADHD.

Selectinga Partner

Perhaps one of the most important protective factors is the choice of a life partner, or conversely the choice not to have a life partner, for those for whomrelationshipissuesareparticularlystressfulor daunting. Many adults with ADHD choose a part- ner whose strengths lie in their areas of weak- ness-organization, planfulness, and attention to detail. Such a choice can be very wise if the partner with A D H D does not allow him, or herself to become overly reliant and dependent, leading to inevitable resentment on the part of the non- ADHD spouse. In some instances, however, the more organized partner also tends to be impatient and critical, leading to chronic stress and low self- esteem in the ADHD spouse-a very poor choice indeed if one is trying to build in protective factors.

Others with ADHD go to the opposite extreme, choosing a partner who has more severe ADHD patterns than they do. This may be a defensive choice, after the experience of rejection by a more organized but critical partner. Such a partnership can be an exciting roller coaster ride, but is often fraught with crises. The ideal choice is a more organized partner who appreciates the ADHD spouse for the liveliness, spontaneity, creativity, interest, and stimulation they bring to the relation- ship, while not being overly distressed by the ADHD patterns of forgetfulness and disorder that are inevitable to some degree.

The psychotherapist working with a single A D H D client or one going through separation and divorce can provide very helpful counsel as the client ventures into the world of dating. An

approach for Nick. Both Nick and his parents real- ized that as he, appropriately, left home again in the next year or two that he would need to think ser- iously about building “protective factors” into his independent life-through careful choices of where helived,howhelived,andwithwhomhelived.Nick was ready to try his wings, and this time his flight was less likely to end in a crash landing.

THE CHALLENGES OF THE MIDDLE ADULT YEARS

Once the initial challenges of leaving home are past, the adult with ADHD has many challenges ahead. He or she also has a huge range of critical choices to make-of career, of lifestyle, of life part- ner, of parenthood-that can either worsen or reduce ADHD symptoms. As discussed earlier, an essential role for the therapist to take in working with young adults is to help them learn to make ADHD-friendly life choices. However, in working with adults in their 30s and beyond, I have dis- covered that most have already made these critical life choices before they seek treatment and before they are introduced to the concept of the “protect- ive factors” of an ADHD-friendly lifestyle.

Unfortunately, many of them have made deci- sions that are decidedly ADHD unfriendly, for example, a mother of five children under the age of 8, who sought a diagnosis of her own ADHD following the diagnosis of her twin 7-year-olds. She had already made irrevocable choices that would be daunting for anyone but close to impossible for her, with the challenges of ADHD. Other choices, however, aren’t irrevocable, although they may be very costly to change. For example, one man choose to earn a law degree-after much hard work-only to realize later that his ADHD and learning disabilities would make the pursuit of this profession continually exhausting and unre- warding. Another family had chosen to purchase an older home that was in much need of repair and maintenance, without taking the husband’s A D H D

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adult with ADHD, whether already in a committed relationship or just entering into new relationships, needs guidance from the therapist about how to introduce the topic of ADHD and how to educate the significant other about the challenges of ADHD while retaining full responsibility for man- aging the challenges of ADHD him- or herself. The client can also greatly benefit from considering the pros and cons of each newly emerging relationship from the vantage point of whether it will be likely to worsen or lessen his or her ADHD patterns.

Career Choices and Changes

As mentioned earlier, it is critically important for the ADHD specialist to develop the skills to address a range of career issues that typically chal- lenge the adult with ADHD. Workplace issues re- lated to ADHD are among the most common difficultiesthat bring adults for treatment. To war- rant calling ourselves adulthood ADHD special- ists, we must develop a set of skills that allow us to address these issues, just as a childhood ADHD specialist must address educational issues. We need not become career counselors, but we should be able to advise our clients on ADHD-friendly career choices, and we should have intimate knowledge of typical workplace dilemmas and the types of strat- egies needed to overcome them.

We need to familiarize ourselves with the laws pertaining to disabilities and how they apply (or don’t apply) to our clients. Very importantly, we need to be able to advise our clients whether it is in their best interest to disclose their disability at work and whether they should formally request accom- modations or work on compensatory strategies without any formal assistance from their employer. There is currently much debate about what consti- tutes a disability and who qualifies for accommo- dations. In most workplace situations, however, I have found that official disclosure and accommo- dations are not often called for, except in extreme circumstances. We need not become disability law

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experts to assist our clients, but we certainly should become familiar with current case law and be able to advise our clients about the most effective ap- proaches to take in dealing with workplace difficul- ties related to their ADHD.

Other Critical Issues

Although beyond the scope of this chapter, there are other critical issues that the adulthood ADHD specialist should be prepared to deal with. The ther- apist should be aware of gender-specific issues for women with ADHD, including the impact of pre- menstrual syndrome (PMS), perimenopause, and menopause on the cognitive functioning of women with ADHD. It is not uncommon, for example, for PMS to severely impact a woman with ADHD and thus to need to be treated actively as a comorbid condition. Parenting issues also pose a great chal- lengeformostadultswithADHD.Theyarelikelyto have children with ADHD and to experience inten- sified struggles because they have difficulty with the very issues for which their children need assist- ance. Single parenting, faced by many women with ADHD, poses an even greater set of challengesbe- cause there is no partner to share the burden and provide a counterbalance. And finally, A D H D can pose unique challengesin the later adult years, when the support and structure provided by a career andl or a spouse may be lost.

TREATING ADULTS WITH ADHD I N THEIR MIDDLE YEARS

The followingcase history is intended to illustrate the multiple levels on which the ADHD specialist must work in treating adults. I have chosen a female case history in order to provide a balance, since the preceding two case histories are of young males. Although fewer females than males are diagnosed ADHD, the ratio among adults is changing rapidly, approaching a more equal ratio of males to females.

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in her father (although never diagnosed). Early childhood academic history is one of a bright child who chronically underachieved. She was very disorganized and forgetful and a chronic pro- crastinator. Consistency and follow-through have eluded her throughout her life; however, high abil- ity has allowed her to pass from one academic level to the next, albeit barely in many instances. When compared to her peers (i.e., others with counseling and law degrees) she shows marked dysfunction. Cecile offers us a good example of a highly capable individual who is unable to meet her potential due to a complex cluster of psychiatric difficulties, one of which is ADHD.

Neurocognitive Treatment Approaches

Remember, in approaching any client from a neurocognitive perspective we are trying to assist the client to: (1) function better cognitively-i.e., to focus, concentrate, plan, and evaluate, better; (2) to develop compensatory strategies that will decrease the ADHD tendencies; and (3) to change the envir- onment so that it is more supportive, more ADHD friendly.

Improve Cognitive Functioning

Medication Psychostimulant medication is one of the most immediate and powerful ways to im- prove cognitive functioning for adults with ADHD. In Cecile’s case, the medication issue was compli- cated by her history of alcoholism. Her psychiatrist, inexperienced in treating adults with ADHD, was understandably reluctant to prescribe potentially addictive stimulant medication to Cecile in addi- tion to the antidepressants she was already taking. Often alcohol and/or marijuana are attempts at self-medication for ADHD, and psychostimulant medication could provide the ability to focus andaccomplish goals that would lower her frustra- tion level and therefore reduce the likelihood of

The case also involves multiple diagnoses, in- cluding alcoholism and depression, offering a good example of dealing with related comorbid conditions. And a major issue involved in this woman’s treatment related to employment, allow- ing discussion how a clinician can approach career issues from an ADHD perspective. Lastly, since the woman I’ll be discussing has earned not one but two graduate level degrees, it allows us to address the issue of whether an adult can legitimately be diagnosed with ADHD while being able to reach this level of achievement.

Cedewasasinglewomaninherearly40switha long history of depression and alcoholism when she was referred to me for evaluation for possible ADHD. Despite years of medication and psycho- therapy, her life remained in complete disorder. A bright woman, she had earned degrees in counsel- ing and in law, although she had never been able to pursue either profession. Financial problems had kept her from paying off student loans so that she could receive her transcript from grad school and apply for licensure as a counselor. Law school had been completed in an alcoholic haze. She graduated at the bottom of her class and had never studied consistently enough to pass the bar exam.

Despite being in recovery for over seven years, she continued to struggle with huge financial prob- lems. Bills were paid late, her apartment was in a permanent state of chaos, and she had recently quit her job due to stress, overwhelming paperwork, and a difficult, demanding supervisor. Cecile was an attractive, but overweight, soft-spoken woman who invariably arrived late for our appointments- anywhere from 10 to 30 minutes. Sometimes she missed the appointment altogether, having over- slept. Despite antidepressants, despite successful recovery from active alcoholism, Cecile was unable to take charge of her life. Her psychiatrist began to suspect that ADHD might play a part in her prob- lems with life management.

First, let’s briefly address the issue of whether C e d e warrants a diagnosis of ADHD. She reports a family history in which A D H D seems very likely

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relapsing. With the understanding that we would both closely monitor Cecile, the psychiatrist agreed to continue her antidepressant medication and to begin to prescribe a stimulant as well. At my urging, however, and in view of her eight years of sobriety, the psychiatrist cautiously began to pre- scribeAdderall@.CecilefunctionedwellonAdder- all and found that she felt more alert and able to remain focused on a task.

Exercise Successfully engaging an adult with A D H D in regular exercise, given a history of lethargy and depression and given a lifelong diffi- culty with consistency and follow-through, is diffi- cult. While exercise was guiltily avoided for many months after commencing treatment, severalfactors suddenly came together (a new job, spring weather, lowered depression) to lead to Cecile’s positive re- sponse to a notice in the newspaper. No-fee training sessions were offered to adults who were out of physical condition to help them prepare for a mara- thon, to be held in six months. Cecile, to her own amazement, contacted a friend and together they signed up, relegated to the slowest group. Even more to her amazement, in response to the structure and group support, Cecile took her training ser- iously and ran or exercised five or more days a week. As the spring days lengthened and the pounds gradually melted away, her motivation was maintained. She reported increased energy and focus at work after several weeks of regular exercise.

Adequate Sleep and Nutrition Poor sleeping and eating habits are very common among adults with ADHD. They are, as a group, typically night owls who chronically sleep-deprive themselves and have difficulty rising on time in the morning. Recent surveys have shown that women with ADHD, in particular, tend to crave carbohydrates and to resort to binge eating, leading to low energy and highly variable blood sugar levels. Although with less suc- cess than with exercise, our treatment regularly focused on her sleeping and eating habits.

Kathleen G. Nadeau

Compensatory Strategies

The second prong of the three-pronged neuro- cognitive approach is to help the client develop compensatory strategies to cope better with the challenges of everyday life. The first compensatory strategy challenge was for her to arrive on time for her appointments. Late arrival seemed a function of both depression and ADHD. She had difficulty sleeping, which led to enormous reluctance to rise when her alarm sounded early in the morning. We focused on night patterns that might improve sleep, dual alarm clocks, and ways to streamline her morning routine. Success was mixed, but gradually improved. We worked on a number of such strat- egies: developing a regular place to put bills and important paperwork until she took care of them; self-calming strategies before bedtime, to try to achieve an earlier bedtime; setting aside a regular evening at home to clean and organize her apart- ment; learning to use a day timer to plan her days and her weeks.

Another practical theme was never far from our sessions-the urgent, practical need to better manage her money and her enormous debt load. Until she could either earn her counselor’s license or pass the bar exam, her job potential and earning power were significantlylimited. Both of these pro-

jects required money-paying off an overdue stu- dent loan and saving the money to pay for the review class, preparatory to taking the bar exam. We examined her typical ADHD pattern of “leaking” money-spending small and medium sums of money frequently, sums she could ill afford4ab fares when she was late, expensive coffee and pastries when she was needing a psycho- logical pick-me-up, purchasing lunch because she hadn’t been organized enough to bring lunch from home, etc. Because detailed record keeping is typ- ically difficult for adults with ADHD, we estab- lished a weekly cash allowance. She would go to an ATM machine each Friday, withdraw a set, affordable amount, and then make her cash ex- penditure decisions for the week based on how

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and initiative. (Such unofficial “accommodations” are often the most effectiveway to arrange the work environment to better suit an individual with ADHD.) She also requested permission to work at home on days when she had an intensive writing project. Procrastination patterns re-emerged, and she engaged in several all-night marathons at work doing last-minute preparations for a conference. We focused on ways to improve this pattern through partnering with others and by setting intermediate deadlines.

Co-MorbidAnxiety, Depression and Alcoholism

Cecile had been sober for eight years. With my encouragement, she continued to be active in Alco- holics Anonymous, which continued to support her sobriety and offered her a structured, constructive social outlet.

From the very beginning of our work together, the practical “neurocognitive” approaches just out- lined were woven together with a focus on more “psychological” issues. Cecile struggled with both lonelinessandatendencytowithdrawwhenshewas depressed. We focused on how both depression and ADHD could contribute to social isolation. I ad- vised her that making social plans is typically diffi- cult for individuals with ADHD and suggested that she look for regularly occurring social activities that she need not plan but only need attend. Shejoined a singlesgroup at church and began to participate in a weight-loss support group as well.

Cecile was also troubled by dysfunctional pat- terns within her family, and we focused on these as various issues arose with her mother, brother or sister. She explored her patterns of dependency and worked on developing a different, more adult rela- tionship with her mother.

As her emotional health increased, Cecile remarked that she felt her social isolation had a different character now. She no longer felt such a strong urge to withdraw, but found that she was

much cash she had in her wallet. That way, each day she made very concrete decisions-would I rather spend $2.50 for a specialty coffee several days or eat lunch out with a friend on Saturday? If I need to buy cosmetics at the drug store, then I’d better pack my lunch for the rest of the week.

Environmental Changes

Workplace The biggest “environmental” issue facing Cecile was her unemployment. In a typically ADHD fashion, she had quit a highly stressfuljob without having found another position, assuming she would have little trouble finding employment. As bills mounted and depression and anxiety rose, she felt less and less able to organize herself for a job search. At the time she entered therapy for her ADHD she had been unemployed for two months, had mounting debts, and depended increasingly on her mother for moral support and financial bailouts-a pattern she deplored but had reverted to repeatedly throughout her adult life.

We analyzed her work history, pinpointing aspects of jobs that she had enjoyed as well as factors that had been her downfall in previous

jobs. Cecile’sself-esteemwaslowandhersenseof discouragement was great. Meanwhile, she had a weekly assignment from me to scan the Sunday paper for job possibilities, to circle those for which she wanted to apply, and to bring the job descrip- tions to each session so we could analyze them in terms of ADHD friendliness and her specificinter- ests, strengths, and weaknesses. Understanding her need for structure and support, she engaged the help of both a friend and her mother in tailoring her rksumk and completing applications for each job that seemed appropriate. Within several months, Cecile was successfully re-employed.

Now she faced the day-to-day reality of how ADHD affected her on the job. We strategized ways to reduce distractions in her crowded office environment by shifting the position and direction of her desk. This was not done as a formal “accom- modation” but simply in response to her request

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less satisfied with the relationships she had formed when she was much more dysfunctional. I talked to her about this as a sign of health and personal growth. She began to think about ways she could meet different people, outside of the context of the self-help groups that had been her main social outlet for many years.

After a year in treatment, Cecile continued to face huge challenges-she had far to go to eradi- cate her debt, she needed to pay off student loans in order to obtain her counseling license or to pay for the prep course to take the bar exam. She had, however, pinpointed a good career direction that would allow her to use her clinical and legal skills together by working with abused children. She continued to train for her marathon and continued to work on developing better spending habits that would allow her to take better control of many aspects of her life. She was actively seeking a more gratifying personal life. In general terms, she was learning to stay the course. The intermediate gains that she had made gave her greatly increased confidence that she could meet longer-term goals. Cecile had come to understand the concept of building “protective factors” into her life and to recognize the circumstances that had repeatedly led to ADHD crises and depression in the past. The coping strategies that she had learned helped her to recognize the signs of depression or of encroaching ADHD patterns and to take active steps to keep herself from sinking again into serious dysfunction.

SUMMARY

There are many parallels between the types of interventions and clinical skills necessary to be effective in treating children and adults with ADHD. For children, the necessary “protective factors” that can minimize ADHD are provided by adults-by parents, teachers, coaches, tutors,

Kathleen G. Nadeau

and others. As clinicians working with adults, we need to introduce the concept of these “protective factors”-of creating an ADHD-friendly life- style-and help adults with A D H D build such protective factors into their adult life.

Because ADHD is a neurobiological condition, we need to be prepared to work with adults clients on a neurocognitive level, supporting improved cognitive functioning through medication and better health habits, teaching coping skills and com- pensatory strategies, and helping the client to de- velop a more supportive environment, including the workplace environment. At the same time, we must treat the secondary anxiety and depression that are so frequently found in adults with ADHD, as well as the commonly comorbid conditions. As a result, both the diagnosis and treatment of adults with ADHD is complex and calls for a broad set of clinical skills.

Because the workplace is the environment in which our adult clients spend the majority of their waking hours, we need the skillsto help them iden- tify and findjobs appropriate to their strengths and weaknesses.We also need to help them definework- place problems related to their ADHD as well as to develop strategies to reduce any negative impact that ADHD may have on their job performance.

In addition to this specialized set of ADHD- focused clinical tools, we must, in the final analysis, function as sensitive and supportive clinicians, seeing our clients as the complex human beings they are and never treating them in a formulaic or simplistic fashion as a person defined by their ADHD.

REFERENCES

Goldstein,S.,& Goldstein,M.(1998).Managing attentionde$cit hyperactivity disorder in children: A guide for practitioners. New York: Wiley.

Changing the Mindset of Adults with ADHD

Strategies for Fostering Hope, Optimism, and Resilience

Robert B. Brooks. Ph.D

Several years ago I received a poignant letter from a man in his mid-40s who knew that I was collecting life stories from children and adults with ADHD. He was diagnosed with ADHD as an adult and noted, “When I found out about my ADHD I felt no relief. The depth of my anger and hurt surprised my therapist.. ..I’ve had lots of rejec- tions: loves lost, great jobs blown. I take all of this personally so all these rejections mean they’re my fault. Then the diagnosis comes, and it confirms what others have said about me: that something was wrong, that I’m defective, or just plain no damn good.”

He continued, “My time has past.. ..I wish you well on your research. You can’t help me but I’m willing to be used as a ‘bad example’ for those younger than me….Because for them, perhaps, there’s still some hope.”

The pain, distress, feelings of hopelessness, and honesty of this man were evident throughout his letter.

In contrast, a number of years ago I worked with an adolescent with ADHD who described his condition in the following way:

Clinician’sGuideto Adult ADHD:
AssessmentandIntervention
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I sat in the red chair, listening behind the old un- breakable desk, while the teacher rambled out our next in-class assignment, listening, focusing on the words as they came from her lips. Her lips stopped, and I reached for my math book, setting it down on my desk, my pencil in my right hand, ready to work. But wait a minute! What was the assignment? I turned to the classmates on both sides, but they were already working away, scratching the graphite into numbers on the standard gray sheet of paper.

ADD haunted me in everything I did. I did not know how to react to the situations around me….In fifth grade the kids would slide down the ice-covered hill, like toboggans on the slope. I would join in, but what at first seemed to be fun turned into an abusive and painful experience. The kids would try to hit me as they slid down, their bodies crashing into mine, knocking the wind out of me, leaving me gasping for breath amongst my assailants, frozen in fear against the next onslaught. Yet each day, I returned. . . . Yet these experiences of pain have led me to my interest in others. Whenever I see a child being teased, I remember. I want to rush in and defend, to annihilate the inhumanity of harassment.

The young man who wrote these words, who committed himself to helping others, who turned despair into optimism, realized his dream and is a physician today.

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Two men, each diagnosed with ADHD, and yet each views himself and the world so differently. Each possesses a different mindset or assumptions about his condition and his future. One is filled with hope, the other with hopelessness and despair. One is resilient, the other cannot even entertain the notion that things might improve.

What factors contribute to these very different mindsets? In this chapter I will review how the major characteristics of adults with ADHD, evident since childhood, shape the mindset of these individ- uals, a mindset often permeated with negative thoughts and feelings.I will examine how this nega- tive mindset often prompts coping behaviors that turn out to be counterproductive and self-defeating, intensifying rather than relieving sadness. Finally, I will describe the features of a positive mindset and what we can do as clinicians to reinforce these fea- tures in adults with ADHD.

THE CHARACTERISTICS OF ADULTS WITH ADHD

Adults with the diagnosis of ADHD are not a homogeneous group. Their cognitive styles and be- haviors that led to being diagnosed with ADHD do not define their entire functioning or existence. However, there are certain core behaviors that many possess that distinguish them to a greater or lesser degree from individuals without ADHD. These behaviors elicit responses from others, re- sponses that contribute to the formation of their mindset. Unfortunately, in far too many instances the mindset of individuals with A D H D is filled with negativity. The following represent a selected list of those behaviors that exert the strongest impact on their lives.

Impulsivity

One of the most prominent characteristics of individuals with A D H D is their impulsivity. They

Robert B. Brooks

are often described as acting before they think, of failing to consider the consequences of their behav- iors. As children they are likely to blurt out answers in a classroom, or push their peers out of the way to be first in line, or place their finger in a light socket to see what happens, or climb a tall tree without considering the dangers. Adults will remind them how to behave in certain situations and they will agree. However, moments later they seemingly forget what they have just been taught, behaving in ways that are in stark contrast to what they have been told. It is easy to interpret their behaviors as manipulative or oppositional, but as Barkley (1995) and others observe, it is not that they don’t know what to do, but rather that they are so impulsive they don’t use what they know.

One observes similar patterns of behaviors in adults with ADHD. They may rush through tasks, or fail to demonstrate social skills by saying things that others experience as abrasive, or engage in risk-taking activities. I recall a couple I worked with in therapy. The husband with A D H D con- stantly interrupted his wife because he had import- ant things to say. At the beginning of one session, his wife was furious. Earlier that day he had im- petuously quit his job when his supervisor asked him to make some modifications on a project. Ap- parently, he told his supervisor that he knew more than the supervisor and that the latter should “get off his back or he would quit.” The supervisor accepted his offer to quit.

As these examples suggest, impulsivity is often reflected in a lack of self-discipline or self-control. Goleman (1995) has highlighted self-discipline as a major ingredient of emotional intelligence, which he defines as “being able to motivate oneself and persist in the face of frustrations; to control im- pulse and delay gratification; to regulate one’s moods and keep distress from swamping the ability to think; to empathize and to hope” (p. 34). Gole- man’s definition of emotional intelligence has direct bearing on other features of adults with ADHD as well.

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with ADHD but also to those who interact with

them. As one 9-year-old boy told me about his

father with ADHD, “I never know how he’s going to feel 01 act. It’s scary sometimes.”

Disorganization

One of the most frequent complaints about indi- viduals with A D H D is their difficulty with organiza- tion. As children and adolescents, they are the ones whosedesksinschoollookasifatornadohasstruck, whose three-ring binders that appeared so neat the first day of school quickly fall prey to different sub- jects being mixed together, who fail to complete homework assignments, who finally finish assign- ments that somehow are lost or misplaced on the way from home to school (for many ofthese children it seems that a black hole exists between home and school, sucking up assignments and papers with great regularity), and who constantly search for lost socks, shoes, coats, and book bags.

This pattern typically follows them into their adult years. They lose things, forget where they placed their keys, cannot locate bills to pay, neglect to jot down an important appointment in their book, or fail to complete a project at work because they have misjudged the time required or become distracted with two other projects. Needless to say, their time management skills leave much to be de- sired. As one man with ADHD sadly related, “I feel I have no control of my life. I can’t keep track of things. I can’t keep track of my schedule. I spend all of my energy trying to keep things in order, but you would never know it from the outcome.”

Rigidity, Inflexibility, and Insatiability

The other side of the coin of impulsivity and disorganization is the lack of flexibility that many adults with ADHD demonstrate. Someone observ- ing their behavior might be puzzled how someone

low FrustrationTolerance

Closely linked to an impulsive style is how quickly adults with A D H D become frustrated and angry. This frustration is evident in many situ- ations. If a task is difficult and not very interesting, they are quick to give up. If someone doesn’t re- spond to what they want, they are quick to anger. One man with ADHD had a 10-year-old son with the same disorder. Instead of being empathic and appreciating his son’s struggles with homework, he would shout, “Just try harder! You always give up! Do you want to be a loser in life?”

Adults with ADHD have difficulty tolerating their own shortcomings as well as the shortcomings of others. It is not unusual for them to cast blame on others when things do not go well. They often expect others to change but may not be as willing to change themselves. On the surface this unwillingness may appear as a statement that they are right and others wrong, but often their reluctance to change is rooted in feelings of helplessness. As one woman with ADHD told me, “I just felt I couldn’t change my angry outbursts at my kids. I felt terrible but I blamed them and told them that if they met their responsibilities and treated me with more respect, I wouldn’t have to shout at them or spank them. But I didn’t take any responsibility for my own behavior.” Her insight was to be the first step toward change.

Moodiness

Many adults with ADHD are burdened by fluc- tuations in mood. One moment they may feel happy, only to have feelings of sadness dominate a few moments later. Some clinicians contend that the depression is primarily biologically based, while others feel that it is in response to years of frustra- tion and failure. As with any affective disorder, most likely both biology and environment interact to different degrees with different individuals to contribute to the moodiness and depression. These shifts in mood are burdensome not only to adults

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can be so impulsive and disorganized at one moment and so rigid the next. On the one hand this rigidity may exemplify, in part, a desperate attempt to cope with the disorganization and lack of control in one’s life, but it also seems to be another example of a failure of self-regulation.

Children will manifest this pattern by having difficulty with transitions. Thus, in school they take a great deal of time to get started with an activity. When the teacher informs the class it is time to stop this activity and begin a new one (e.g., shifting from reading to math), they will not want to stop the first activity until they have completed it. If they are involved with a game or task at night, they do not want to go to bed until they have finished it, much to the frustration of their parents. Relatedly, I recall a number of youngsters with ADHD whom I would remind with at least 10 minutes left in our therapy session that our meeting would be over in 10 minutes. Even with this re- minder, some would plead or argue for another few minutes to finish a drawing or a game.

This characteristic of inflexibility will frequently be manifested in the difficulty children with A D H D have in accepting “no7’as an answer to a request (demand?) they have made. Their cognitive style does not leave room for compromise. They believe that their requests are reasonable and that when adults do not comply, the adults are being unfair and arbitrary. They frequently perceive only one solution to the problem, namely, that others comply with their wishes, and when this does not occur they often experience meltdowns, with ac- companying tantrums (Greene, 1998).

A feature closely linked to inflexibilityand a fail- ure to compromise is what might be labeled “insati- ability.” I have been impressed by the number of parents who have described their children with ADHD as “impossible to please.” Onemother tear- fully said, “From the moment my son was born, I felt I could not satisfy him. He always seemed to want moreandmoreandmore.Ashegotolder,notoywas good enough for him, even if we had given him a choice of what toy he could buy. I thought I must

Robert B. Brooks

have done something really wrong to have a child who never seemed satisfied or grateful.”

This inborn feeling of insatiability, which is not easily quenched, leads to the perception that the world is unfair. When insatiability, inflexibility, and rigidity become interwoven into a cognitive and emotional tapestry, which is not unusual in children with ADHD, the end result are children who are demanding, unhappy, difficult to soothe, and unable to compromise. While this may seem an overly bleak picture, it is found in many youngsters with so-called “difficult” temperaments (Brooks & Goldstein, 2001; Chess & Thomas, 1987). Children with A D H D typically fall under the category of temperamentally “difficult.”

In adults, insatiability and inflexibility are dis- played in many aspects of their lives. They are seldom satisfied even when they succeed. Enjoy- ment is fleeting at best. In couples therapy, when one member of the couple has ADHD, it is not surprising to hear the other describe his or her spouse as difficult to please, unhappy, always seeing the glass as half empty, possessing an intense need to be right, perceiving compromise as giving in, and frequently not paying attention. Often, the spouse with A D H D minimizes these descriptions by saying he or she would feel fine if other people were more giving and considerate. In their parenting roles, the inflexibility may be expressed in an authoritarian style replete with anger. It is little wonder that tension and friction become dom- inant features of families where one or more members have ADHD.

A Dearth of Empathy

Many individuals with ADHD struggle to be empathic. While this difficulty with empathy is closely linked to the characteristics I have already described, I believe that given its importance in our day-to-day interactions it deserves special mention. Goleman (1995) has highlighted empathy as a major ingredient of emotional intelligence.

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ability, and a lack of empathy are the possible manifestations of the biological underpinnings of ADHD, as we have already seen, these characteris- tics will impact on almost all aspects of aperson’s life. They will serve as a major influence in determining thewaysinwhichwerespondtoothers,howtheyres- pond to us, and how successful we are in the many personal and professional activities in which we engage.

Fromchildhood, the particular styleofmanyindi- viduals with ADHD asjust described results in poor peer relationships as well as compromises in school and subsequent work performance. Slowly,negative assumptions or perceptions about oneself and others take shape, becoming an integral part of an indivi- dual’smindset. In turn, thismindset plays a powerful role in determining one’s behaviors in a wide spec- trum of situations, generating a cycle of negative beliefs, a loss of hope, and self-defeating behaviors.

The following are several of the main interrelated features of this negative mindset, with suggestions at the end of this section of ways that clinicians might assess this mindset via interview questions. Also, questionnaires such as Seligman’s (1990) “learned optimism” scale may be used in conjunction with interview material to evaluate the positive or nega- tive qualities of an individual’s mindset.

I Do Not Have a Great Deal of Controlof My life

One of the hallmarks of a positive mindset is feeling a sense of control over what transpires in one’s life, together with a realistic appraisal of those areas over which one has control and those thatarebeyond one’sinfluence.AsCovey(1989)has eloquently noted, all people have “circles of con- cern,” but effective people recognize and use their time and energy to focus on their “circles of influ- ence”; that is, they are proactive rather than reactive. Stress is frequently linked to the belief “I have little say or control over the important things that occur in my life.”

In simple terms empathy may be defined as the capacity to put oneself inside the shoes of other people and to see the world through their eyes. Em- pathic people are able to take the perspective of others, even when they disagree with these others. They attempt to understand how their words and deeds are experienced and how others would de- scribe them. They reflect upon and take responsi- bility for their behavior. They are able to realistically assess and appreciate the “social scene.”

Cognitive and emotional skills are necessary for empathy to develop. If one examines the character- istics of children and adults with ADHD, one can appreciate why empathy is often compromised. It is a great struggle to take the perspective of another when we are impulsive, frustrated, or moody, when we quickly interpret the actions of others as with- holding or unfair, when we believe that others are not listening to us, and when we feel we are being cheated. A man with ADHD I worked with in ther- apy for several years summed up his improvement with the following insightful statement: “It wasn’t until I could slow down and realistically separate what I was feeling from the intention of others that I could become a more empathic person.”

In contrast to this comment was one offered by a young adult with A D H D during a discussion of empathy. He argued, “Why should I really care about how I come across to others or how others see me? If I think too much about that, if I act too nice, they might take further advantage of me.” This young man’s definition of empathy was much different. He viewed empathy as a weapon for manipulation rather than as a skill to foster more satisfying relationships. As long as he main- tained this perspective it would be difficult for him to engage in comfortable, satisfying relationships.

THE UNFORTUNATE MINDSET OF ADULTS WITH ADHD

If impulsivity, low frustration tolerance, moodi- ness, disorganization, rigidity, inflexibility, insati-

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The very nature of the characteristics of A D H D contribute to a feeling of not being in control. For example, if one behaves impulsively without con- sidering the consequences, negative results are likely to follow that are often interpreted as a lack of con- trol of one’s actions. As one woman told me, “I always yell at my kids. I tell myself not to, but then when they don’t do what I want them to do I get so frustrated so quickly that I scream. I feel terrible afterwards.” A man with ADHD said, “No one really listens to me. Nothing I do seems to work.”

Or as another example, if one is insatiable, const- antly seekingunobtainablegratification, thencontin- ued hunger and frustration are the likely outcome, as isthefeelingthat “nothingIdoisenoughtogetwhat1 want” or “people won’t give me what I deserve.”

When I Am Successful It Is BasedonluckorChance

Whether we are aware of it or not, when we suc- ceed or fail at things in our life we offer ourselves different explanations for these successes and fail- ures. As suggested by attribution theory (Weiner, 1974), these explanations are linked to our self- esteem and sense of optimism. Attribution theory has been studied relative to individuals with atten- tional and learning problems as a target population (Brooks, 1999;Canino, 1981;Licht, 1983).Children and adults with high self-esteem perceive their suc- cesses as based in great part on their own efforts or abilities. These individuals assume realistic owner- ship for their achievements. They believe they are active participants in their own success.

In contrast, individuals with low self-esteemtyp- icallyattribute successto things outside of their con- trol, such as luck, chance, or fate. One child with ADHD told me that his good grade on a test was “pure luck.” Another said, “The teacher made the testeasy.”AnadultwithADHDvividlysaidthather successin life was like “a house made out of cards.” She added, “I feel that if any kind of wind comes along, my entire facade of success will crumble.”

Robert B. Brooks

If you believe that your success is not rooted in your resources and effort but rather in luck or chance or things beyond your control, then it is difficult to be confident about experiencing success in the future. In such a case, a loss of hope becomes a dominant feature of one’s life.

Failure Indicates My Inadequacy as a Person

Just as attribution theory highlights differences in how individuals understand the successes in their lives, so too does it clarify how failure is perceived. Children and adults with high self-esteemtypically believe that mistakes are experiences from which to learn rather than feel defeated. Mistakes are attrib- uted to variables that can be modified, such as a lack of adequate effort when engaged in reaching a realistically attainable goal or the use of ineffective strategies when studying for a test. A child request- ing assistance to learn the strategies involved in solving math problems or an adult registering for a computer course in response to struggles to master the computer represent examples of taking positive action to confront mistakes.

In contrast, individuals with low self-esteem, which is often present in ADHD, are vulnerable to thinking that they cannot correct the situation or overcome the obstacle. They view mistakes as a consequence of factors that are not modifiable, such as a lack of ability or intelligence, and this belief breeds a feeling of helplessness and hopeless- ness. They begin to believe that regardless of what they do, few, if any, positive outcomes will appear. The probability of future success is diminished be- cause these people expect to fail and, thus, retreat from the challenges at hand. I have seen this pat- tern with a number of adults with ADHD.

I’m lessWorthyThan Others

If one encounters many failure situations, it is not difficult to understand how self-esteem is ad-

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ibility, and low frustration tolerance, reinforce the feeling that things are not fair. This belief was vividly and directly captured by a boy who wrote to me, “Why did I have to be born with ADHD? It’s not fair.”

The sense of unfairness is manifested in other ways during one’s youth. One middle school boy with A D H D was angry with a teacher who gave him a D grade for the semester. On five tests he had received three F’s, one D, and one B. In actuality, the teacher might have been justified in giving him a failing grade. The boy complained that he de- served a B as a grade since one of his test scores was a B. When I pointed out that the teacher was probably basing the grade on all five tests, the boy persisted, “But I got a B on a test!”

At first I thought that he realized that he did not deserve a B but was attempting to convince himself or me that he did. However, I soon appreciated that his seeming distortion of the situation actually re- flected a couple of the characteristics associated with ADHD. One, he was conditioned to perceive things as unfair when he did not get what he wanted, and two, his cognitive style was to view situations in a rigid, black-and-white fashion, not allowing him to assume another perspective. Once he felt he deserved a B, there was no room for a different view.

This feeling of unfairness, which becomes an on- going, emotional strain, is also apparent in adults with ADHD. They harbor constant complaints about employers, spouses, and salespeople they be- lieve are unfair. While at times there may be justifi- cation to these complaints, frequently they represent anger at feeling misunderstood and not having demands met.

People Seem Angry with Me

Closely related to this last point but deserving separate mention is the sense that others are angry with you. This perception, although exaggerated at times, does have some basis in reality. People do

versely affected. True self-esteem, or what Lerner (1996) calls “earned self-esteem,” is based on realis- ticaccomplishment. Eachsuccessservesasastepup the ladder of future success. However, when mis- takes, failure, and negative feedback are major parts of a person’s landscape, there is little room for high self-esteemor confidence.

Self-doubts appear early in the lives of many children with ADHD and continue into their adult- hood. Sentiments such as “I can’t do that, it’s too tough” or “This is stupid” (the child in fact feels stupid) are voiced by children as young as 5 and 6. Just as each success serves as the foundation for future success, so too does each setback serve as a reinforcement of the idea “I am not very capable.”

A man with ADHD said to me, “If I have any doubts about my ability to do something, these doubts quickly multiply and interfere with my ever being able to succeed. I see myself as klutzy and I have trouble concentrating. The other day I went to assemble a toy we had bought for my son. The moment I saw the number of parts and the directions I told myself, ‘I’ll never be able to do that. I can’t understand directions. I bet 1’11have pieces left over.’ And guess what? When I finished, the toy didn’t work and I had pieces left over.” With much insight he added, “The moment I toldmyself I couldn’t do it, the outcome was no longer in question.”

The man mentioned at the beginning of this chapter described these feelings of low self-worth when he wrote to me, “Then the diagnosis comes, and it confirms what others have said about me: that something was wrong, that I’m defective, or just plain no damn good.”

As we shall see, these negative feelings of low self-worth trigger coping strategies that often ex- acerbate rather than improve the situation.

The World Is Unfair

Individuals with ADHD often believe that situ- ations and people are unfair. The characteristics of A D H D noted earlier, such as insatiability, inflex-

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not find it easy to be with someone who comes across as self-centered, impulsive, demanding. An- noyance and frustration often pervade relation- ships, contributing to the feeling that the other people are angry with me. Unfortunately, if em- pathy is lacking, the response to this feeling is to become angry rather than attempt to resolve the conditions that are reinforcing the anger.

A woman with ADHD told me that her brother and sister were always “ganging up” on her and calling her “inconsiderate” and “selfish.” She said that she let them know in “no uncertain terms” that they were the selfish ones and should go see a therapist. She was unable to consider the possibility that her siblings were accurate about her behavior, instead feeling that they were angry because of their “personality problems” and their ‘‘jealousy’’of her talents.

I Have little, If Anything, to Offer the World

A sense of self-esteem and dignity is nurtured when individuals feel that they are making a contribution to their world, that their actions makes a positive difference (Brooks, 1999; Brooks & Goldstein, 2001). This hypothesis was supported by narrative research I conducted when I asked adults to iden- tify one of the most positive moments they ever had in school. The most frequent answer I received concerned when they were asked to help out in some manner (e.g., painting a mural on the wall, watering plants, tutoring younger children). The act of assisting others typically reinforces the belief “I am worthwhile, I have something positive to offer others.” The second man I described at the beginning of this chapter is an example of someone who found a way of turning his hurt into helping others, namely, by becoming a physician.

Many adults with ADHD who possess a negative mindset view themselves as adding little, if anything, tothelivesofothers.ThefirstmanImentionedatthe beginning of this chapter, who gave me permission

Robert B. Brooks to use his story as an example to others, emphasized

the negative in doing so (“My time has past. …I wish you well on your research. You can’t help me but I’m willing to be used as a ‘example’for those younger than me.. ..Because for them, perhaps, there’s still some hope”).

The belief that one has little to contribute to others lessens feelings of competence and a sense of worth and dignity. One man I saw with ADHD summed up his feelingswhen he told me with great honesty, “I think the only thing I have ever given others is heartache.”

I Am Pessimistic That Things Will Improve

This feature of a negative mindset is also under- standable given the other beliefs that many individ- uals with ADHD hold. It is difficult to be optimistic when people feel little control of their lives, when they have difficulty taking ownership for success, when they believe people are unfair and angry, and when they are unable to see any ways in which they make a positive difference in their world. Pes- simism about future success and happiness often results in a self-fulfilling prophecy for failure. If you expect that you will continue to experience un- happiness and failure, subtly or not so subtly your actions will lead to these expectations being realized. An ongoing cycle of expected failure and actual failure is a very powerful force in contributing to a pessimistic outlook that is devoid of a sense of hope.

This sense of pessimism and loss of hope was poignantly reflected in the writings of a young man with ADHD explaining why he dropped out of high school. “My alarm goes off and I awake to a new day. At 7:OO in the morning my stomach is queasy and my head hurts. ‘Oh God, another day of school.’ Too sick to eat breakfast, I stand in the shower saying, ‘Maybe it will be a good day,’ but deep inside I know it will be the same.” Given these strong beliefs it is little wonder that he perceived that his only way of coping was to leave school.

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ASSESSING THE MINDSET OF INDIVIDUALSWITH ADHD

It is important to emphasize that while not all adults with ADHD develop a negative mindset, many appear to possess some if not all of these characteristics. Before examining the coping strat- egies used by adults with ADHD and the ways in which a clinician can help replace a negative mind- set with a mindset that is filled with more positive and resilient beliefs, it may be helpful to articulate the kinds of questions that clinicians can raise to assess the mindset of individuals with ADHD.

While paper-and-pencil procedures have been developed to evaluate a person’s self-esteem, sense of competence, and optimism or pessimism, as a clinician I have found that interview questions remain the best resource for obtaining revealing information. Interview questions permit a more in-depth view of an individual’s perspective, and they allow you to follow up and elaborate on par- ticular points. The following represent a sample of questions that may be raised (see Table 7.1). It is important to remember that many of these ques- tions serve as a springboard to further questions and discussion, helping us to understand the mind- set of adults with ADHD.

All of these questions tap into the views that people have of themselves, of others, of their com- petencies and vulnerabilities, of their relationships, of their hopes for the future, of their beliefs if they can bring about change. In essence, the answers to these questions represent a mindset, or a set of assumptions about oneself and others.

COPING STRATEGIES: HELPING OR EXACERBATING THE PROBLEM?

We all rely upon a variety of coping strategies to deal with stresses and challenges in our lives. Some coping strategies appear to be effective, helping individuals to deal successfully with the challenges

TABLE 7.1 Sample Assessment Questions

How does having ADHD affect your life?
What are the negative and positive aspects of having ADHD? What things would you like to see changed in your life?
What have you attempted to do to change any of these things? In what areas have you been successful?
Why do you believe you have been successful?
In what areas have you been unsuccessful?
What do you think has contributed to your not being successful? When you are not successfulat a certain task, what is your usual response? Give a few examples
Are there people who are trying to be of help to you?
Who are they?
How do you know they are trying to be of help?
What is one of the most helpful things someone did for you? Are there any people who actually seem to be interfering with your chances for success?
In what way are they behaving to keep you from being successful?
What is one of the least helpful or even hurtful things someone did to you?
If you could change one or two things about yourself beginning tomorrow, what would they be?
How would you start? Lookingayearortwoahead,howdoyouseeyourlifechanging? For things to improve, do you think others have to become more tolerant of your having ADHD, or do you feel you have to begin to make some changes, or is it a combination of the two?

they face. Other coping behaviors may afford tem- porary or illusory relief, but not only do they fail to resolve the problem, they actually worsen the situ- ation. One of the questions raised in the last section is an attempt to gather information about the ways in which a person copes: “When you are not suc- cessful at a certain task, what is your usual re- sponse? Give a few examples.”

The question of what differentiates an effective from an ineffective coping strategy does not always invite an easy answer. Paradoxically, what I might consider to be an ineffective coping strategy may actually diminish stress for at least a certain period of time more than what I would perceive to be an effective coping strategy. As one example, im- agine you were invited to give a presentation at a local organization and you are fearful of public

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speaking. One way of coping with the anxiety would be to offer the excuse that you are busy and unable to accept the offer. The immediate feel- ing is typically relief. One might argue that this way of coping was effective since it lessened stress. However, as a clinician I have found that eventu- ally what replaces this relief is regret. Regret at having fled away from a challenge.

For example, a woman with ADHD whose main coping behavior was to avoid situations that she felt could lead to mistakes and embarrassment came to see me. She said that she was constantly telling her two children to “stick with things and not give up” but that she felt like “a hypocrite” since she had spent much of her life “running away from things that might lead to failure and humili- ation.” She noted, “When I say no to a certain re- quest, I feel okay for a few minutes, but then I hate myself for being so scared and always avoiding tough things. But then I keep running from things.”

Now imagine that instead of immediately offer- ing an excuse not to speak, this woman said yes and then considered ways to cope with the anxiety she was experiencing. She listened to a tape or read a book about lessening the anxiety of public speak- ing. She practiced her speech using a tape recorder or in front of a trusted friend or relative. As she coped in this way, she might remain anxious, but most likely her preparation would lead to a more than satisfactory performance. The fact that she did not back away from the challenge, but rather faced it directly, would be one of the strongest determinants of feeling a sense of self-worth. If she took this route, although her coping behavior might not at first diminish her distress, I believe that eventually it would, since she faced rather than fled from a problematic event.

A coping behavior may be deemed effective when individuals confront challenging situations rather than retreat from them, when coping leads to emotional growth and greater feelings of self- worth, and when coping helps people to experience a sense of control of their own lives, when they

Robert B. Brooks

believe they are masters of their own fate. The factors that contribute to whether an individual uses effective or ineffective ways of coping appear to be based on an ongoing, dynamic interaction between inborn temperamental factors and envir- onmental conditions (Brooks, 1984).

Since a major feature of the mindset of many individuals with ADHD is their belief that they are not very competent, that they are destined to fail, and that they do not control their own destiny, they are likely to recruit coping strategies that prove self-defeating and do not result in emotional growth or in success.

There are some common ineffective coping strat- egies I have observed with adults with ADHD. As clinicians we must remember that these strategies, although self-defeating, originally served a protect- ive purpose. They were called upon in an attempt to avoid the possibility of further failure, humiliation, and embarrassment. If we keep this purpose in mind we will recognize that our task is to help adults with ADHD feel less vulnerable so that they are more secure and better able to replace ineffective means of coping with effective strategies. The following represent some of these self-defeating coping behav- iors, several of which can occur at the same time.

Avoiding

This coping behavior is represented by the actions of the woman described earlier who turned down a speaking request. People will usually avoid a task that they believe will lead to failure. I worked with one man with ADHD who described himself as “klutzy and unathletic.” When friends asked him to join in a relatively noncompetitive local softball or basketball game, he always said no. Yet a number of other people who also were not athletically inclined did participate. In the course of therapy this man reflected, “I spend more time and energy avoiding things than I do trying things. I guess I’ll never know what I’m capable of doing, but I hate to look foolish.”

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“He just doesn’t like me. He’s unfair.” However, as our therapy work progressed, he was able to ac- knowledge that the work his boss expected of him was no different from that of other employees. He was able to realize that blaming his boss was a way of coping with his own feelings of inadequacy and also represented the mindset that the world is unfair.

Controlling

As noted earlier, a number of adults with A D H D feel little, if any, control of what occurs in their lives, so a sense of helplessness is not an uncommon result. In response, some individuals attempt to take command and become dictatorial, telling others what to do or how to run their business or their lives. This coping behavior is typically reinforced by problems with empathy and poor social skills. A man with ADHD lost severaljobs as he fell into the pattern of telling his manager how the department should be run. On a couple of occasions he did not fulfill certain responsibilities that he felt “made no sense.” He also was free with advice to his col- leagues about how they might do a better job.

A woman with ADHD who felt ‘‘overwhelmed’’ by the requirements of parenting resorted to micro- managing everything her 10- and 8-year-old sons did. Her need to control their lives was based, in part, on her feelings of inadequacy as a parent as well as a need to “keep the household in order.”

Aggressive Behavior

Closely tied to several other counterproductive coping behaviors, such as externalizing and con- trolling, is being aggressive and striking out at others. If people feel that others are unfair or that the task is too difficult, some may respond by avoiding the situation, while others may resort to angry outbursts bordering on bullying. The specific coping behavior that is used will often be

Quitting

This coping style is similar to avoiding but is used to describe people who begin a task and then quit as soon as they encounter difficulty. Often this pattern is established early in children’s lives, con- tinuing into their adulthood. I have heard many examples of children with ADHD who start a mu- sical instrument or join a sports team, only to leave in a short time with some excuse. A woman I knew had quit college. When she returned several years later to take courses, her style was to drop certain courses, either saying they were boring or required too much work given her busy schedule. However, her quitting was truly rooted in her feeling that she could not succeed at the task.

Rationalizing

This strategy is frequently used by adults with ADHD. It involves offering excuses for perceived difficulties and failure rather than accepting re- sponsibility. The woman who quit college because the courses were too “boring” provides an example of the use of rationalization. A man I saw in ther- apy refused to go for a job interview for a new position, saying he was certain it would not be a challenge. He offered this opinion even before he had obtained all of the details of the new job. In fact, he was quite frightened of taking on new challenges, which he saw as eventuating in failure.

At times, rationalization assumes the form of externalizing, that is, blaming other people or exter- nal events for unsatisfactory outcomes. Examples include a woman with A D H D who explained her poor interpersonal relations by contending that other people were unfair to her for no reason or a man who blamed his boss for his own poor work performance. He told me, “My boss knows I have ADHD, but yet he gives me very detailed work to do, more detailed than my coworkers get.” When I wondered why his boss would do this, he answered,

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influenced by an individual’s temperament as well as his or her life experiences. I have found that a number of adults with A D H D will manifest being aggressive with a heavy dose of rationalization; that is, they will rationalize their aggressive behav- ior by arguing that their actions were justified given the ways in which the other person behaved toward them.

A rather driven president of an engineering com- pany was diagnosed with ADHD. While brilliant in his scientificwork, he had difficulty accepting vul- nerabilities in himself or in others; his ability to be empathic was limited at best. He had an intense need to be in control, which his position in the company permitted him to do. He left college after his junior year with a transcript filled with “incom- plete~,’’feeling that many of the requirements to complete a class were “stupid.” He then quit his first two jobs after arguments with his supervisors. He began his own company to show his professors “I don’t need a college degree to be successful” and to show his former employers that if they “listened to me, their companies would be much more suc- cessful.”

A downturn in his own business resulted in symptoms of anxiety, and he was referred to a psychiatrist for a medication consultation. The psychiatrist completed an evaluation and made a diagnosis of ADHD as well as an anxiety disorder. This man was placed on medication and referred to me. As he became more comfortable in therapy, he shared his disappointment at not having finished college and added, “It’s not a good example for my teenage son and daughter.”

He then discussed his relationship with his em- ployees, especially since many of his middle man- agers were leaving the company. As he described his interactions it was obvious that he demanded perfection, rooted, in part, in a driving force to prove his professors and former employers wrong. When something did not work out, rather than discuss it rationally with his staff, he would become angry and say some hurtful things. At one meeting he shouted, “What a dumb thing to do!” while at

Robert B. Brooks

another he asked one of his managers, “Are you using your brains?” He justified these outbursts by saying, “I get angry when people fall short of what their performance should be, and it’s good to let them know how disappointed I am.”

Given his lack of empathy and his need to be in control, he had little awareness of how this form of motivation was counterproductive; it basically mo- tivated his staff to avoid him or leave the company. Much of the emphasis of our therapy was to help him become more accepting of his own vulnerabil- ities and more empathic toward other people in his life.

Acting Impulsively by Rushing Through Things

Although impulsivity is a major characteristic of ADHD, it may also represent a way of coping. It is not unusual for some adults to want to finish a challenging task or burdensome chore as quickly as possible “to get it over with.” The obvious prob- lem is that the more quickly and impulsively the task is done, the more likely that the final product will be riddled with mistakes and flaws. A negative cycle is established, since these mistakes reinforce for adults with ADHD that they are not very com- petent, and to deal with these feelingsthey resort to one or several of the self-defeating coping behav- iors that have been described in this section. Success becomes more and more elusive, while a negative mindset becomes increasingly entrenched.

STEPS FOR CHANGING NEGATIVE INTO POSITIVE MINDSETS

As clinicians, one of our main roles when working with individuals with A D H D burdened by a nega- tive mindset and accompanying self-defeating coping behaviors is to help them to replace their negative feelings and thoughts with an optimistic,

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harness the pain into a positive force of under- standing and helpfulness, eventuating in his be- coming a physician.

The questions I outlined earlier to assess the mindset of adults with A D H D can serve as the catalyst for demystifying ADHD and promoting greater self-awareness. As an example, when I asked a man with ADHD to describe both a suc- cessful and an unsuccessful experience from his life, his answers were very revealing. It was almost as if he had read and decided to adhere to the tenets of attribution theory. The successful experience he re- counted was of a tennis match against a friend who was a good tennis player. He won the match and told me in therapy, “I was lucky. My friend didn’t play at his best. I even wondered if he was trying to let me win since he had beaten me so often.”

As an unsuccessful experience, he recalled an incident from college when he failed the initial exam given in a mathematics course. His first thought was, “I’m really stupid in math. I’ll never pass.” He dropped the class. He then confided in me, “After I dropped the class, I started to blame the teacher and thought, ‘If the teacher were a better teacher, I would have been able to handle the material in the class and pass it.’ ” He used two main coping strategies to deal with his sense of failure, the first was quitting and the next was ra- tionalizing/externalizing.

Although it may seem very obvious to the reader that this man with ADHD had a negative mindset, that he was unable to take credit for his success and felt like he would never learn from his failure, he was unaware of his assumptions and how they affected his life. In therapy he offered a number of other examples of this way of thinking. To assist him to become more cognizant of these negative assumptions and to begin to challenge him to change, I borrowed a technique described by solu- tion-oriented therapists, namely to elicit “excep- tions” to typical ways of behaving and thinking. Exceptions pertain to situations in which certain problems do not occur or occur less frequently (de Shazer, 1991;Murphy, 1997).

positive outlook and more adaptive ways of man- agingstressandpressure.Wemust serveasacatalyst to generate a positive cycle in which the individual engages in activities that lead to fulfillment, satisfac- tion, and success. As each success chips away at negative feelings, realistic risk taking and the con- fronting of challenges are likely to follow. As noted earlier, success breeds success.

1. DemystifyingMindsets

An initial step in changing negative mindsets is to help individuals define and understand (a) the assumptions that they have about themselves (in- cluding ADHD) and others and (b) how these as- sumptions prompt certain behaviors and coping strategies that may be self-defeating. In essence, this first step emphasizes the strengthening of self- awareness, which Goleman (1995) views as a basic component of emotional intelligence.

As examples, the two men described at the be- ginning of this chapter had different understand- ings of ADHD. The first man, who was diagnosed as an adult with ADHD, had already sufferedyears of humiliation and failure. In his case, the despair and hopelessness were apparently such entrenched features of his mindset that the diagnosis did not help to demystify what had occurred all of these years. Rather, the diagnosis was quickly incorpor- ated into his negative mindset as a confirmation “that something was wrong, that I’m defective, or just plain no damn good.”

In contrast, the man who became a physician learned of his A D H D earlier in his life. His parents and doctors explained what it meant and how it manifested itself. Understanding his condition helped to demystify it, so it was not as foreboding. While he experienced pain and rejection, he also was helped to see that one could learn ways of coping with ADHD, that it was not a sentence for lifelong misery. Even when upset, he could see a light at the end of the tunnel and could appreciate that he could learn from his experiences. He could

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I have modified to some extent the “exception” technique by asking individuals to think of times that they were successfulin a certain domain rather than focusing on when the problem did not occur. I asked this man with ADHD to reflect upon times that he was successful and attributed his success to his own resources and of times he made mistakes and was able to learn from those mistakes.

He struggled at first to think of examples but with some encouragement was able to do so. Both illustrations involved the actions of a coach. He recalled as a young teenager playing in a youth basketball league; he almost single-handedly won a playoff game by making two steals and three baskets in the last minute. “When the game was over and my coach congratulated me, I said, ‘I was really lucky.’ My coach said really strongly, ‘It wasn’t luck, it was your determination and skill.’ The way he said it made me believe him.”

He also recalled that from the first day of prac- tice this coach actually told the team that if they thought their success was based on luck, they did not realize the benefits of practice, hard work, and teamwork. “I also remember when I had a bad game and was really feeling down. The coach put his hand on my shoulder and said even the pros have bad games. He reminded me of my good games and then pointed out how I wasn’t following through on my shot. I wish I could have remem- bered this coach’s lessons. During the year he was my coach I felt more confident than ever before, but unfortunately the feeling didn’t last long.”

He then described the coach he had the following year, who “believed in sarcasm and put- downs and never seemed to offer encouragement.” He continued:

I remember one game where we were losing by one point. A teammate threw the ball to me with a few seconds to go and it went off my hands and out of bounds. We lost the game. I don’t know if the throw to me was too hard or I was just too anxious to get it and shoot. I felt terrible and then even worse when the coach said in front of everyone that I missed the ball because “I didn’t have good hands.” Can you imagine that? I wasn’t

Robert B. Brooks

that secure to begin with, and his remark made me feel like I would never be good. After that, anytime someone threw the ball to me, I felt uncomfortable. I’m still upset with myself that I let his remark have such a negative impact on me.

These examples, especially the “exceptions” to his current mindset, helped him to appreciate and understand the assumptions that directed his way of thinking and behaving and set the stage for the second step involved in developing a more positive mindset, namely, articulating the components of this mindset. This articulation provides clinicians with a compass in guiding interventions to nurture a resilient mindset.

2. DefiningThe Main Components of a Positive, Resilient Mindset

In many ways the features of a positive mindset are the mirror image of the earlier description of a negative mindset. They include the following.

a. I will learn to distinguish what I have control over from that which I do not. I will focus my time and energy over those things over which I have con- trol, since I am the author of my life. As was noted earlier, one of the hallmarks of effective people is their belief that they are masters of their own des- tiny. Research focusing on successful adults with learning and attentional difficulties found that they did not adhere to a martyr role. They never asked, “Why me?” but instead believed, “I had no control of being born with ADHD, but what I do have control over is how I deal with ADHD.”

Gerber, Ginsberg, and Reiff (1992) studied the ways in which successful adults with learning dis- abilities view themselves (I believe the same is true for adults with ADHD) and emphasize the import- ance of feeling in control when they write, “Control is the key to success for adults with learning dis- abilities.. ..Control meant taking charge of one’s life and adapting and shaping oneself in order to

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they use these strengths in their daily lives. It is also why I use the technique of searching for “ex- ceptions” when people respond that they don’t feel they are very good at anything. I want to begin to plant the seeds that will flower into areas of com- petence.

d. I believe that mistakes are opportunities for learning and growth. No one is really thrilled when they make mistakes or fail. However, as clin- icians we recognize that one of our most important tasks is to help people feel less intimidated by mis- takes. When mistakes are viewed as situations from which to learn, people are more willing to take realistic risks rather than backing away from chal- lenges. They do not expend an inordinate amount of time and energy fleeing from possible setbacks. Rather, their efforts are directed toward developing plans of action to succeed; if they do not succeed, they reflect upon what they have learned and what they can do differently next time. Their outlook is optimistic.

e. I make a positive difference in the world. A basic component of emotional well-being appears to be the belief that one’s actions benefit others (Brooks & Goldstein, 2001). As a therapist I have witnessed countless examples of individuals, many with ADHD, who engage in activities that make a positive difference (e.g., being involved in a charity, serving as a coach in a youth sports league, helping at a senior citizen center); in the process their own sense of dignity and self-worth is enhanced, and the roots of a resilient mindset are secured.

3. DevelopingaPlanofAction for Change

Once clinicians help adults with ADHD gain a clearer picture of what ADHD entails, and once these adults can appreciate the assumptions that characterize their mindset and guide their behav- iors, the next step is to articulate a problem-solving

move ahead.. . . Control was the fuel that fired their success” (p. 479).

The sense of being in control is associated with the attitude that if changes are to occur in my life, I must take responsibility for these changes and not wait for others to come to my rescue or immedi- ately satisfy my needs. Such a perspective not only lessens the sense that the world is unfair and ungiv- ing but also places responsibility for change within oneself.

b. Success can be based on my own strengths and resources. This feature of a resilient mindset is closely aligned with feeling a sense of control of one’s life. While effective people will give credit to individuals who contributed to their success, they also believe that their success rests largely on their own efforts. In essence, they assume ownership for what occurs in their lives.

A woman with A D H D constantly downplayed any of her accomplishments, an attitude that not only diminished her enjoyment when she succeeded, but also lessened the probability of future achieve- ment. Adhering to a negative script, she had the following knee-jerk reaction to success: “I was lucky this time. It probably won’t happen again.” Each success elicited the same thoughts. In her case, she segregated one success from the next, so they did not build on each other to change her negative mindset. As she became more aware of this self- defeating attitude, she was able to adopt a realistic outlook in which she could say, “I did well because I planned what I was going to do and worked hard.”

c. I have “islands of competence.” We all have areas of strength, or what I refer to as islands of competence. However, as we have seen, a number of adults with ADHD fail to acknowledge or ap- preciate their strengths. People with a more posi- tive, resilient mindset are able to identify their islands of competence. It is for this reason that in my clinical work I ask my patients to tell me dir- ectly what they view as their strengths and how

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model for change. The model I predicate my inter- ventions upon, developed by psychologist Myrna Shure for children and adolescents, appears equally relevant for adults (Shure, 1994,2000). My modifi- cation of Shure’s basic model includes the following components, all of which I believe have a commonsense, achievable quality to them.

a. Articulate both short-term and long-term goals for change. If adults with A D H D have developed a negative mindset that offers little hope for the future and we have helped them to understand that mindsets can be changed, a first step is to have them begin to articulate the changes they would like to see occur in their lives. It is often a help to divide these changes into short-term and long-term goals, with the short-term goals contributing to the realization of the long-terms goals.

b. Select a few goals to address. I have dis- covered that while some adults with ADHD struggle to articulate goals (as therapists we can help them to do so), others are able to generate a long list. However, sometimes their impulsivity and low frustration tolerance prompt them to begin to work on all of these goals at once, almost a certain prescription for failure. Instead, as therapists we must assist them to prioritize their goals and to select one or two on which to give initial focus (O’Hanlon, 1999). We want to maximize the prob- ability that the goals they have selected are achiev- able so that success will be more likely. Once we have selected the areas they wish to address, we can help to articulate both the short-term and long- terms components of these goals.

As an example, in my sessions with adults with ADHD I take out a sheet of paper and ask them what they would like to see change in their lives. We write down their responses and then select one or two areas on which to focus. The very exercise of examining and selecting these one or two areas serves several purposes. It helps to define precise and realistic goals. In addition, it serves to chal- lenge and modify various components of a negative

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mindset, such as feelings of low self-esteem and not having control over one’s life.

I once worked with a man with ADHD who defined as two of his goals “strengthening his mari- tal relationship” and “focusing on his physical health” (he was overweight). We discussed both of these goals, which at first were cast in somewhat general terms. While describing his marital rela- tionship, aspects of a negative mindset were imme- diately apparent. He initially placed responsibility for change on his wife contending that “she was not as supportive and loving as she could be” and he also felt that she was unfair in what she expected him to do around the house.

The characteristics of a negative mindset, espe- cially the sense that he had little, if any, control of his life, were also operating when we discussed the issue of his physical health. He complained that he had a “poor metabolism,” noting that “I can just smell food and I put on weight.” He also said that his job demands made it almost impossible to engage in a regular exercise routine.

In essence, he was erecting obstacles to the achievement of goals before they were well defined and planned. He externalized responsibility by ar- guing that his wife needed to be more supportive and that she should not expect too much of him since he had ADHD; he blamed his poor fitness on his me- tabolism and job schedule. While there might be some truth in all of these assertions, if he continued to adhere to these obstacles to success,it would keep him from asking the following question: “Even given these obstacles, what is it that I can do to slowly begin to deal with the problems at hand?”

In my role as a therapist, I pointed out, in an empathic way, the self-defeating patterns he had established, and we reframed his goals in the following way.

0 Improving his marital relationship was set as his long-term goal. Short-term goals were to spend more time with his wife, be less critical of her, and fulfill two designated household responsibilities on a regular basis.

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relationship. I wondered how often he gave his wife positive feedback; it was not easy for him to offer an example. Consequently, we discussed his finding opportunities throughout the week (not just at a “scheduled” meeting) to compliment his wife. In essence, we were searching for ways for him to change the “negative scripts” that had become en- trenched in his style of relating (Brooks & Gold- stein, 2001).

Concerning the goal of becoming more fit, he thought it would be easier if he and his wife con- sulted a nutritionist. He felt it was important for his wife to be present since she often bought the food and prepared the meals in the house. He told me, “Her support will be crucial.” Also, he joined a local health club. But before he started an exercise regimen, he met with one of the staff and they developed a realistic and achievable plan for him. A course of action that may come easily for an adult without ADHD often requires specific input and feedback for adults with ADHD.

d. Have criteria for evaluating the success of a plan of action. Another key issue involved when developing a strategy to reach one’s stated goals is the criteria to use to assess whether the plan is working effectively. In some instances, the criteria are very concrete, such as weight loss and greater fitness (e.g., losing a certain amount of weight in a specified time period or being able to jog two miles within a month). In other instances, an assessment of effectiveness may require more work in defining criteria for success, such as when the goal is “an improved relationship with one’s spouse.” This man did monitor that he and his wife were meeting at the time they had agreed upon and that they were discussing issues in the marriage that both judged to be important; he even found it helpful to keep a record for himself of the number of times he complimented his wife. He said, “At first I thought it would seem artificial, but it soon became a more natural part of my new script.” The evalu- ation of the effectiveness of any intervention should also include realistic time limits.

0 Improving his physical fitness was set as his long-term goal. His short-term goal was to go on a healthy diet, begin exercising on a regular basis, and lose a pound each week until he had shed 20 pounds.

c. Develop realistic, achievable plans to reach designated goals. Given the impulsivity, poor planning skills, and low frustration tolerance evi- dent in even medicated adults with ADHD, the importance of designing a realistic plan of action is of paramount importance. For example, I once worked with a woman with ADHD who, similar to the man in the last example, wanted to lose weight through diet and exercise. However, she was in such a “rush” to do so that she went on what could be seen as a starvation diet and she immediately started doing several hours of exercise a day, having done little exercise previously. She began to lose weight quickly, but her initial exuberance and feeling of success were soon replaced by ex- haustion and not feeling well physically. Before long, she resorted to her old habits, asserting, “This diet and exercise stuff really doesn’t work.” As obvious as it may appear to the reader that this woman’s approach was doomed to failure, the pos- sibility of failure was not at first evident to her.

Returning to the man whose goals were to de- velop a better relationship with his wife and to become more physically fit, once he accepted his role in making changes, we explored the actions he could take to reach his goals. We discussed sharing with his wife his wish to spend time with her and their setting aside a time each week to be together with no distractions. While some may wonder why this couple could not just discuss things on a spontaneous basis, the issue of time management for many adults with ADHD is poor. Thus, estab- lishing a set time to chat was important for this man.

We also considered different topics that he wanted to discuss with her. But as he described them to me, many seemed critical of his wife and were certain to lead to increased tension in their

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e. Consider possible obstacles to the goals being achieved as well as how these obstacles will be han- dled. In addition to developing criteria to assess the effectiveness of different strategies, I have found that it is important to discuss openly the possibility that a plan may not work. It is not unusual for me to say after we have considered a plan, “What if it doesn’t work?” This comment is not offered as a self-fulfillingprophecy for failure, since I then add, “Some plans seem great in my office but they don’t work outside the office. So let’s think of possible backup plans should the first one prove ineffec- tive.”

I believe that is it important in advance to acknowledge that some courses of action will prove ineffective but that we can learn from these. I found that when I did not discuss the possibility of failure, the reaction of many adults with ADHD to a plan that proved unsuccessful was to view it as another indication of their ineffectiveness. It lowered even further their sense of self-worth, trig- gered feelings of sadness, prompted anger toward themselves or toward me as their therapist, and reinforced a more pessimistic view of what they could accomplish to change their lives. However, by proactively considering possible obstacles as well as subsequent strategies, these adults were less vulnerable to feelings of failure and better equipped to handle disappointments. By possessing backup plans they also felt more in control of their lives rather than victims or martyrs.

The man we have been discussing learned that if at times his wife did not want to talk, instead of getting angry at her, he would simply say, “That’s okay, we can find another time.” In terms of exer- cising regularly, when he began to find it “boring” to go to the gym, he made plans with a friend who was also using the same gym to go together, in effect supporting and encouraging each other (ap- parently his friend also struggled with following through on things).

Given the negative mindset of many adults with ADHD that assumes the worst and takes each failure as an indication of how unworthy they are,

it is critical to build in this step of anticipating that interventions may not work and designing alterna- tive strategies.

f. Change the goals if repeated efforts at success do not work. If our strategies to reach particular goals continue to lead to failure, it is often a signal that the goals may need to be changed. Goals that appear reasonable may actually turn out to be too ambitious, or other, unanticipated factors may interfere with their success. When this occurs, it is important to review and modify the original goals.

A woman with ADHD set as one of her goals to spend a half-hour each evening playing the piano, an activity she not only enjoyed but that helped to relax her. In our sessions she decided that if this goal of playing piano a half-hour each evening didn’t work, her backup plan was to practice every other evening. Given her other responsibil- ities, she found it difficult to set aside a half-hour every evening to play piano. She resorted to the backup plan, namely, to practice every other evening. She discovered, much to her dismay, that she began to miss some of her practices every other evening. She said to me, “Another example of my not being able to follow through on things.”

I asked what she thought would help her find time to play the piano, especially since it was an activity that brought her enjoyment. At first she fell prey to a negative mindset and contended that “probably nothing would work. I can’t even suc- ceed at something I enjoy doing.” However, with some encouragement she offered an interesting ob- servation, together with a revised goal. “A half- hour doesn’t seem like much but maybe it is. I wonder what would happen if I began by setting aside 15 minutes each evening.”

While some may judge this modification of a goal as simplistic, I viewed it as a major step for- ward in terms of indicating that she was altering her negative mindset. The very task of contemplat- ing and implementing a new goal was a reflection that she was moving beyond the feeling that she was helpless, that the situation was hopeless, and

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takes ongoing work and effort. As a clinician I have discovered that until a more positive mindset is firmly rooted, there will be many occasions when the old mindset rears its ugly head and begins once again to be a dominating force.

It is for this reason that I spend time helping adults with ADHD to recognize (a) the feelings and beliefs that signal the possibility that a negative mindset is taking hold (e.g., believing “I am stupid” or “Iamworthless’’or “Iwill alwaysfail” or,asthe woman I described earlier told me, her success in life was like “a house made of cards. I feel that if any kind of wind comes along, my entire facade of success will crumble”), (b) the different coping strategies that are being used to manage these feel- ings and which ones are actually counterproduc- tive, (c) the need for more realistic goals and plans of action, and (d) the acceptance of one’s strengths and vulnerabilities.

CONCLUDING THOUGHTS ABOUT TWO MEN

Returning to the stories of the two men at the beginning of this chapter, I believe that the one who went on to become a physician was aided by an early diagnosis, ongoing support from his parents and therapists, discovering his islands of compe- tence (e.g., helping others), and learning as much as he could about A D H D (he even volunteered as a research assistant during one summer on a project related to ADHD). He increasingly gained a feeling of control over his life.

In contrast, the other man did not “discover” his condition until he was in his 40s. Unfortunately, by then his negative mindset was so entrenched and so hardened that all of his life experiences were filtered through this mindset. The pain of continu- ous failure made it difficult for him to find a new path, although I believe even individuals trapped in such a negative mindset can change. They typically require the input and support of therapists and others who can help them to learn about and follow the ideas outlined in this chapter.

that she did not have the resources to find an alternative solution. She discovered, much to her delight, that 15 minutes of practice a night was achievable for her. Not surprisingly, she frequently extended the 15 minutes to 20 or 25 minutes once she was seated at the piano. She perceived this additional time as a “bonus.”

g. As goals are reached, add new goals to re- inforce a positive mindset, and be aware of the negative thoughts that may serve as obstacles to future growth. After one month of practicing piano for 15 minutes a night, she moved to her next goal-playing 20 minutes each evening. The seemingly small accomplishment of playing 15 minutes a night was like climbing Mt. Everest for her. She found that true successis based on realistic accomplishment and that each success reinforces a positive mindset, thereby setting the stage for future success. Feeling more confident, she added a new goal, namely, taking piano lessons once a week to strengthen her skills. She felt that she had achieved a certain level of discipline and commit- ment to take these lessons.

I will never forget the session we had when she came in and said, “My piano teacher feels I have real talent.” In the past, she might have added, “I think the teacher isjust saying this to be nice.” However, her attributions about success had changed. She could now accept the piano teacher’s appraisal. Given her greater self-assurance I could even joke and ask, “Now, you’re certain that your accomplish- ments are not just because of luck or that somehow your fingersjust moved across the piano without any direction from you?” She laughed and said, “No, it’s me in charge.” That statement had great meaning on both a figurative and a literal level. For one of the first times in her life she felt a sense of ownership for her accomplishments.

h. As new goals are added, continue to develop more effective ways of coping that will help to main- tain a positive mindset and strengthen the gains that have been made. Replacing a negative mindset

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As clinicians, we must be empathic and under- stand the world of adults with ADHD. We must provide realistic hope by offering strategies for suc- cess. We must strive to replace a negative mindset with a mindset filled with optimism and promise. This is one of our greatest gifts to individuals with ADHD. When this gift is realized, it offers us a great source of satisfaction as well.

Barkley, R. (1995). Taking charge of ADHD: The complete, authoritative guidefor parents. New York: Guilford Press.

Brooks, R . (1984). Success and failure in middle childhood: An interactionist perspective. In M. D. Levine & P. Satz (Eds.), Middle childhood:Development and dysfunction (pp. 87-128). Baltimore: University Park Press.

Brooks, R. (1999). Fostering resilience in exceptional children: The search for islands of competence. In V. Schwean & D. Saklofske (Eds.), Handbook ofpsychosocial characteristics o j exceptional children (pp. 563-586). New York: Kluwer Aca- demic/Plenum Press.

Brooks, R., & Goldstein, S. (2001). Raising resilient children. Chicago: Contemporary Books.

Canino, F. J. (1981). Learned-helplessnesstheory: Implications for research in learning disabilities. Journal of Special Edu- cation, 15, 471484.

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Chess, S., & Thomas, A. (1987). Know your child. New York: Basic Books.

Covey, S. R. (1989). The 7 habits ofhighly efectivepeople. New York: Simon & Schuster.

de Shazer, S. (1991). Putting dzference to work. New York: Norton.

Gerber, P. J., Ginsberg, R., & Reiff, H . B. (1992). Identifying alterable patterns in employment success for highly success- ful adults with learning disabilities. Journal of Learning Dis- abilities, 25, 475-487.

Goleman, D. (1995).Emotional intelligence.New York: Bantam Books.

Greene, R . (1998). The explosive child. New York: HarpedCol- lins.

Lerner, B. (1996).Self-esteemand excellence:The choiceand the paradox. American Educator, 20, 14-19.

Licht, B. G . (1983). Cognitive-motivational factors that contrib- ute to the achievement of learning-disabled children. Journal ofLearning Disabilities, 16, 483-490.

Murphy, J. J. (1997). Solution-focused counseling in middle and high schools. Alexandria, VA: American Counseling Associ- ation.

O’Hanlon, B. (1999). Do one thing dzferent and other uncom- monly sensible solutions to life’s persistent problems. New York: William Morrow.

Seligman, M. (1990). Learned optimism: How to change your mind and your life. New York: Pocket Books.

Shure, M. B. (1994). Raising a thinking child. New York: Holt. Shure,M.B.(2000).Raising a thinkingpreteen.NewYork: Holt. Weiner, B. (1974). Achievement motivation and attribution

theory. Morristown, NJ: General Learning Press.

A Model of Psychotherapy for Adults with ADHD

Susan Young

This chapter examines psychotherapy for adults with ADHD. Stimulant medication is likely to help individuals with ADHD to make more effective use of psychological intervention. The chapter first reviews the specific problems individuals with ADHD contend with in adulthood and how psychological therapy may help them with these problems. Four vignettes illustrate how the hetero- geneity of ADHD leads to vast individual differ- ences in the expression and sequelae of the disorder. These problems are not restricted to individuals with symptomatic ADHD. ADHD adults in par- tial remission, as well as those in total remission, may also experience relative difficulty in adaptive functioning. Cognitive-behavioral therapy (CBT) is proposed as the most appropriate therapy for individuals with ADHD in adulthood (Young, 1999). This may be applied on an individual or group basis. Therapy should include a psychoedu- cative component in order to help the individual better understand the disorder as well as to im- prove family stability and cohesion. Specific CBT interventions are outlined for the development of time management and organizational skills; planning and problem-solving skills; impulse con-

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trol; interpersonal skills; and the treatment of anger, anxiety, and depression. Contextual factors (e.g., age, employment, and marital status) are likely to influence whether an individual will bene- fit most from individual, group, and/or family work.

The clinical management of adults with ADHD has focused almost exclusively on stimulant medi- cation, yet psychological therapy can play a vital role in addressing their problems (Young, 1999; Young & Harty, 2001). The aim of this chapter is to consider how an individual may best be sup- ported with psychological intervention and to pro- vide guidelinesto this end. The aim of psychological therapy for adults with ADHD is twofold: (1) to adapt the environment around the individual in an attempt to make it one in which he or she can achieve success; and (2) to help the individual de- velop the skills to achieve set goals and develop constructive coping strategies to deal with life chal- lenges and stress. These goals are consistent with Goldstein’s (1997) treatment model of environmen- tal interventions to reduce the consequences of symptoms combined with strategies to reduce the symptoms.

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WHO ARE ADULTS WITH ADHD AND WHAT ARE THEIR PROBLEMS?

Adults with ADHD have difficulties attending to tasks and activities and inhibiting their impulses. They have poor concentration for short, focused work and poor ability to sustain attention over a long period. They act without thinking, which often results in reckless and impetuous behavior. Impul- sivenessmay be an important defining characteristic of ADHD in young adulthood (Young, Toone and Tyson (in submission). Although they do not neces- sarily present with the overactive behavior frequent- ly seen in children, they feel subjectively restless. This means an individual may act without reflection or consideration for the consequences of action. They may be disorganized and forgetful and have planning deficits and poor time management skills. Impetuous, novelty-seeking behavior may result in criminal acts, substance misuse, and dependence.

A comprehensive empirical review of the long- term outcome A D H D is presented in Young (2000) but briefly summarized here. Children with A D H D often have language deficits and school problems and experience academic failure. Many become conduct disordered and have dealings with the police from a young age. These problems often continue into adulthood, when they have antisocial behavior problems and frequent police contact (Hechtman & Weiss, 1986; Satterfield, Hoppe, & Schell, 1982; Satterfield, Swanson, Schell, & Lee, 1994). An increasingly antisocial trajectory is likely to be a significant risk factor for criminal behavior (even in the face of remitting symptoms), and by young adulthood individuals may become indoc- trinated into a criminal culture.

Adults with A D H D often have problems in their work lives, becoming underemployed in their occu- pations relative to their intelligence and their edu- cation and family backgrounds. They frequently experience a high turnover of jobs and/or un- employment. Individuals often report feeling they possess ability yet, unlike their siblings, are unable

to achieve positive outcomes. They often deviate from family expectations of job status by being employed in significantly lower-ranking jobs than those of their siblings. This may reflect the herit- ability of hyperactivity (Swanson et al., 1998),with A D H D siblings also being impaired by dimen- sional features of ADHD. Employers of adults with ADHD have reported that they have poor levels of work performance, are poor in task com- pletion, lack independent skills, and have poor relationships with supervisors (Weiss & Hechtman,

1986).
Interpersonal relationship problems are also pre-

sent, with individuals reporting difficulties main- taining relationships personally, socially, and with work colleagues. ADHD adults are more likely to become divorced or separated (Biederman, Far- aone & Chen, 1993). They may vent frustration on close family members. Aggression may be directed toward loved ones (verbal and/or physical) or the destruction of property.

Our research has shown that individuals with A D H D have an early onset of behavioral problems requiring multiple presentations to childhood psy- chiatric and educational services (Young et a1 (in submission). Yet despite these frequent contacts with clinical and educational services,the diagnosis of ADHD may not have been made until after repeated clinical contacts. Adults with A D H D are likely to have internalized academic and social fail- ure and to have developed problems with self- esteem. Anxiety, depression, and suicidal ideation are common comorbid problems (Biederman, Far- aone & Kieley, 1996; Brent et al., 1988; Young et al., 2001), and poor impulse control may be a determining factor, with individuals being unable to inhibit suicidal ideation and attempts. Individ- uals diagnosed in adulthood (as opposed to having their problems recognized in childhood) may feel that they have been unfairly treated by a system that has not only failed to identify their problems but in some cases labeled them as “untreatable” (Young & Harty, 2001). They may feel angry and bitter and lack trust in service providers.

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of his or her presentation. For example, problems will differ between a single 17-year-old student and an unemployed 32-year-old man living with his partner and two young children.

Gender differences have been shown to be pre- sent in core symptomatology: In childhood, boys display greater levels of motor activity and aggres- sive and antisocial behaviors, while diagnosed girls tend to display higher rates of cognitive impair- ment, language dysfunction, and compromised neurological status (Berry, Shaywitz & Shaywitz, 1985; Biederman, Faraone, & Mick, 1999; James & Taylor, 1990; Kashani, Chapel, Ellis & Shekim, 1979). Females with ADHD also tend to show greater brain metabolism abnormalities than males (Ernst et al., 1994; Zametkin et al., 1993). Thus gender as well as age must be considered in understanding the pathophysiology of ADHD. Gender differences in outcome is a severely neg- lected issue in the literature. Outcome findings in ADHD have traditionally been based on research on males and then sometimes erroneously general- ized to include both sexes. But males have different rates of maturity. The impact of puberty may be quite different between genders. Males’ and females’ socialization and styles of interaction are also disparate. It cannot be assumed that the impli- cations of the A D H D syndrome are the same for both sexes. ADHD is more prevalent in men, by a ratio of approximately 3:1 (Heptinstall & Taylor, 1996), leading many clinicians to operate from a male paradigm. Lability may be the most important construct when considering the emotional function- ing of females with ADHD. Emotional instability characterized by fluctuating anxiety, depression, and sudden mood swings is commonly reported by ADHD females, and the self-regulation of their emotional state may be a primary problem (Nadeau, Quinn, & Littman, 2000; Solden, 1995). In the case of females, therefore, therapy may need to prioritize skills that monitor self-regulation of mood and affect. Men, on the other hand, are more likely to require help with verbal and physical aggression. They are more likely than females to

As one moves from adolescence into adulthood the sum of these problems can seem insurmountable (Lomas & Gartside, 1999). It may be easier to give up trying than to fail again. A longstanding history of failure is likely to result in low self-esteem and demoralization. Comorbid anxiety and depression will lead individuals to avoid certain situations, anticipate failure, lack confidence, and feel misun- derstood by others. Borderline and/or antisocial personality problems may develop as individuals become rigid and inflexible in thought and behav- ior, in addition to having long-term interpersonal relationship problems.

It is important to emphasize that not every person with A D H D will present with all of the problems just discussed. It is vital to identify at the beginning of therapy an individual’s strengths and successful adaptive strategies. Indeed many individ- uals have developed strategies to overcome their problems (e.g., they become self-employed owners of small businesses), reflecting a preference for per- sonal autonomy outside of structured work settings that have expectations of performance and achieve- ment and require appropriate interaction with col- leagues and people in authority (Mannuzza, Klein, Bessler, Malloy, LaPadula, 1993). It is important that therapy emphasize the clients’ strengths and resources. People with ADHD, just as everyone, possess positive qualities that can be built upon. By minimizing the negative effects of the disorder, it is hoped to improve the overall quality of life experienced by adults with A D H D and thereby enhance their sense of control and self-efficacy.

Individual Differences

Many of the problems and difficulties that all individuals face are shared by people with ADHD. Nevertheless there are some fundamental differ- ences that need to be acknowledged by the therapist in order that therapy can be adapted and tailored to the clients’ needs. Particular consideration should be given to the age of the individual and the context

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engage in antisocial and criminal behaviors, which are often opportunistic and unplanned. Thus they may become engaged in an increasingly antisocial trajectory. Developing skills in anger management, problem solving, and impulse control is likely to be a priority target for therapy.

ADHD Graduates

It is reported that many people with ADHD will gradually experience an improvement in some symptoms with maturation (for review see Gold- stein, 1997; Chapter 3 in this book). Traditionally, “graduates” of childhood ADHD have not been routinely offered psychological therapy, for they are no longer considered symptomatic. Yet such individuals often feel that they are “survivors” of a syndrome that has left them with significant per- sonal, social, and occupational consequences. It may be that they are no longer symptomatic- indeed, their ability to attend to information and remain on task may have improved. But they are likely to retain a learned sense of helplessness, re- inforced by years of failure.

This“hangover” ofADHDneedstobeaddressed therapeutically in order to generate change in an individual’s life. Clinicians may be unsympathetic and attribute current difficulties to motivational and attitude problems, with little appreciation that these stem from a sense of insecurity and lack of confidence.Cognitionprecedesbehavior,andgradu- ates of ADHD are likely to need help reappraising their place in life, their capabilities, and their oppor- tunities. Negative assumptions and expectations abouttheabilitytosucceedorsimplycopeinagiven situation are likely to lead individuals to avoid situ- ationsandexercisestheyperceiveasanxietyprovok- ing or unmanageable. Therapy should be supportive and constructive, for example, making use ofmodel- ing and graded exposure techniques. One of the most difficult aspects of therapy will be improving self- efficacy, because the negative experiences of adults with A D H D (whether symptomatic or not) are long

Susan Young

term and deep rooted. Failure has been repeatedly reinforced by more failure. Successes are often min- imized, if recognized at all. In other words, they no longer believe in themselves.

PSYCHOLOGICALTHERAPY

Adults with ADHD present with multiple prob- lems and complex histories. Their strengths may be buried under a mountain of negative thoughts and experiences. They require structure in terms of per- sonal organization and social boundaries. They achieve best in an environment where there are clear rules and expectations of behavior.

Cognitive-behavioral therapy is the most appro- priate therapy for adults with A D H D because it is a collaborative and structured model. This is not to say, however, that other models will be inappropri- ate. For example, marital and systemic therapy may well be required before individual work can commence, for the most pressing issue may be trou- bled family relationships. Adults with A D H D may well become parents of children with A D H D and are often ill equipped to deal with a hard-to- manage, disruptive child. Young adults may well still live at home with parents and siblings, and family therapy may be required to reduce cycles of negative reciprocity and conflict within the family. This could be achieved by identifying differ- ent points of view and acknowledging the impact of ADHD on the feelings and motivations of others. It is not difficult to imagine how traits of disorgan- ization, poor motivation, and aggressive and im- pulsive behavior have a negative impact on family dynamics. Excessive alcohol and substance abuse are also likely to exacerbate existing problems in families that often lack the usual avenues of social support.

Marital dissatisfaction is not uncommon, and non-ADHD partners may have little understand- ing about the disorder and complain that their partner fails to listen to them, that he or she is unreliable, insensitive, argumentative, or irrespon-

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may learn to appreciate the strengths and limitations ofanadultwithADHDanddeveloprealisticexpect- ations of behavior. In this way subtle changes in the environment could be achieved that make it easier for an adult with ADHD to function. For example, partners could learn to give clear, concise instruc- tions that are easy to follow and understand; to write down specific and important instructions; to break down tasks into small, achievable steps rather than set general goals that may be perceived as unobtain- able. Partners should also be encouraged to give consistent and immediate positive feedback in order to encourage an individual to remain on task.

A Cognitive-Behavioral Therapy Model

A cognitive-behavioral approach is likely to be most effective for adults with ADHD, whether ap- plied on an individual or a group basis, because it is structured. It should focus on self-management strategies, although, as discussed, the context in which strategies are offered will vary according to presentation. The clinician will need to adapt the therapy to the individual’s needs at that time. A central tenet of cognitive-behavioral therapy is col- laboration. It is vital to engage and motivate an individual by setting agendas and goals of therapy together. This approach is likely to have face valid- ity for individuals who may feel ambiguity over engaging with (yet another) clinician. It will be vital that they have confidence in the therapist and perceive that the therapist understands their problems and the prognosis of ADHD in adult- hood.

Cognitive-behavioral therapy is usually time limited,withanaverageof 12-1 5sessions.Butadults with ADHD may require extended therapy and sup- port, up to 30 sessions, in order to address their multiple problems. A therapist should not attempt to address everything at once. It is better to focus on agreed, specific issues. The aim is to empower the individual to develop self-efficacy and the

sible. Marital therapy should encourage couples to reexamine their relationship from an A D H D per- spective, to stop blaming each other and reduce conflict.

Psychoeducation

Adults with ADHD often feel misunderstood by their partners, friends, and family. They may feel isolated and alone. It has commonly been reported that they have always felt different in some way from others, even as young children. In spite of the developing understanding and font of know- ledge about ADHD, it is still often considered a disorder of childhood. A psychoeducational com- ponent to therapy is essential in order to dispel erroneous lay beliefs and provide information to explain the etiology, prognosis, and associated factors of the ADHD syndrome. Understanding that their problems have an underlying neurodeve- lopmental basis will be an important step in repairing the self-esteem of people who have long believed themselves to be stupid and/or who have been labeled as lazy by others. Furthermore, by understanding their limitations, individuals can de- velop realistic expectations for performance. This will be especially important when applied to psy- chological therapy; for example, patience is un- likely to be characteristic of adults with ADHD, and information about the disorder can help indi- viduals appreciate that learning new strategies re- quires ongoing practice until a new skill becomes automatic and routine. Thus individuals may stick with a program for longer and not give up at the first hurdle.

Education about the disorder, its prognosis, and its management may facilitate understanding and reduce feelingsof anger and frustration often experi- enced by family members. And CBT is likely to be more beneficial if family members are supportive, develop a working understanding of ADHD, and its associated problems and support the efforts the indi- vidual is making to effect change. Family members

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confidence that change can be achieved. This will require education about the disorder, cognitive restructuring, and reframing of the past. Thus an in- dividual should be taught to challenge negative automatic thoughts, self-monitor performance, rec- ognize errors in thinking, and evaluate cognitive distortions and misattributions. In addition to cog- nitive interventions, the therapist should employ a variety of behavioral techniques, such as graded task assignments, modeling, and role play. Whenever possible, it will be important to elicit core beliefs the individual holds about hidherself, other people, and the world. This will help the therapist to under- stand how the individual perceives the world.

The application of CBT to people with ADHD is discussed in the following sections, which focus specifically on treatment to help individuals de- velop time management and organizational skills; planning and problem-solving skills; impulse con- trol; and interpersonal skills. Cognitive-behavioral therapy for anger management, anxiety, and de- pression is also discussed. These problems are illus- trated using examples from four case vignettes (Anne, Peter, Jane, and Michael) which appear in the Appendix at the end of this chapter.

Time Management and Organizational Skills

A primary complaint of adults with A D H D is that they possess poor time management and or- ganizational skills. Individuals describe themselves as forgetful, resulting in their being late for ap- pointments. They forget to bring necessary items to meetings, such as important papers and work equipment. They have difficulty organizing them- selves, both on a daily basis and more generally when making long-term plans, for they tend not to think ahead and anticipate potential problems. Setting goals and developing strategies to complete goals is likely to be an important focus of therapy for these difficulties.

Such problems can be addressed by introducing notebooks, a diary, or an appointment book and by posting visual reminders in strategic locations.

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The introduction of cues and reminders means a person can make an immediate note of an idea, before a new stimulus distracts them. Individuals should be taught to make lists of things to do and then to prioritize their tasks for the day or week. Jane found this particularly helpful because weekly tasks appeared more achievable when broken down into smaller items to be completed each day. Day lists can be further broken down and prioritized into those items that are imperative to do and those that are less important. Small, imme- diate rewards should be introduced once impera- tive items are completed and again for the completion of less important tasks. Small rewards can in turn be aggregated to earn a greater reward. Jane was able to attend additional exercise classes in the time that opened up from her more efficient time management. Achievements, or learning to complete sets of tasks, may well be rewards in themselves (even if tasks are perceived as monoton- ous), because individuals with A D H D may not have developed a sense of ending or completion from their tendency to start lots of different things and never finish any of them.

Planning and Problem-SolvingSkills

The cognitive deficits of adults with ADHD, in addition to their poor impulse control, are likely to result in inadequate problem-solving skills. Adults with A D H D describe having diffi- culty following through a train of thought in a logical fashion. This may be complicated by diffi- culty with self-expression. They also tend to make rapid decisions, based on inadequate or inappro- priate information, resulting in fundamental errors of attribution and judgment. This may cause mul- tiple long-term problems because they then have to live with the consequences of an overly rapid and ill-informed decision-making process. This, to- gether with a tendency to catastrophize situations, may result in the perception that they have made a total mess of their lives and that nothing ever goes right for them.

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their action. Their search for thrills and novelty may stem from an excessive attraction to immedi- ate reward. They may also have difficulty inhibiting the impulse to avoid aversive tasks and/or situ- ations. Their decision-making processes may also be impulse driven, with an individual making im- portant choices rapidly and without careful consid- eration or planning. A model therapy should aim to teach self-regulation (e.g., to “stop and think”), consider consequences of action, and generate ap- propriate alternatives (Barkley, 1997).

Core deficits in attention and concentration are likely to cause adults with ADHD to act spontan- eously and without consideration of small details or planning. This may lead individuals, like Peter, to get into trouble with the police should they become increasingly involved in antisocial and criminal behavior. Offenses are most likely oppor- tunistic and unplanned. Peter was very entrenched in perceived failure. He could not hold down a job and he stole on impulse to fund his drug habit. Even as a petty criminal he was unsuccessful, and he had a long list of criminal convictions. It was not easy to elicit his strengths or to get him to take a positive perspective. Peter reported he had been a good artist in school, and once this interest had been identified I worked with prison staff to de- velop a rehabilitation program that initially focused on his creative abilities. This represented an area in which he was most likely to obtain a sense of achievement. One problem was getting Peter to engage in sessions at the Art Therapy Center on a regular basis. Peter believed it was a waste of time and that he would not do well in the classes. Peter’s assigned prison officer encouraged him to attend initially for short periods, and gradually he en- gaged with the center. It was hoped that by com- pleting pieces of work and finding satisfaction in the work he produced, he would learn the feeling of achievement. This was a turning point in his re- habilitation. His tutors recommended that he apply for a place in an Art Foundation course when he left prison (which would give him access to attending a university course) but this was too

Therapy should be solution focused and also prepare the individual for future events by outlin- ing a blueprint for coping with new problems. However, it is likely that adults with ADHD may list nonspecific, overarching problems. Peter cited his problems to be “I have difficult motivating myself, I’m lonely, I have difficulty expressing my- self.” In such cases the therapist will need to help the individual break these difficulties down and identify core problems that can be worked on therapeutically. This can be achieved by asking the client to give specific examples of each diffi- culty. Therapy should focus initially on immediate problems that are relatively easy to solve and then progress to long-term aims and goals. A review of progress should regularly be introduced as an op- portunity for positive feedback. In Peter’s case, by attending art therapy sessionshe found a peer set to refer to; by developing his creative skills he partici- pated in an activity that was of interest to him and was able to express himself in his artistic work. Longer-term goals became possible with the pro- spect of Peter’s taking formal qualifications in the subject as he progressed in his classes.

Adults with ADHD have often learned to live with their problems and may have adopted strat- egies that have successfully helped them overcome problems in the past. These strategies should be identified and the individual encouraged to apply them to current problems. It will be very common, however, for individuals to perceive numerous obs- tacles that bar their path to achievement. These must be dealt with by systematically breaking them down into smaller, manageable obstacles and generating various solutions to overcome them. Barriers to this process and difficulties they may have in exploring appropriate solutions (both cognitive and practical) should also be addressed.

Impulse Control

Difficulty with impulse control will lead individ- uals to act without thinking. Adults with ADHD do not think ahead or consider the consequences of

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distant (or difficult)for Peter to envisage. By break- ing down the goal into smaller, achievable steps, or “minigoals,” this became more realistic to Peter (e.g., completing a piece of work that would be required for his application). Thus his focus was more immediate and did not get lost in a perceived hopeless and distant aim.

Anger Management

Adults with ADHD are often hyperaroused in- dividuals with a tendency toward temper or violent outbursts. Cognitive-behavioral techniques can be applied to teach an individual to consider the con- sequences of angry outbursts and to manage the inappropriate expression of anger. There are two ways to manage anger: (1) to bottle it up inside and (2) to direct it toward self or others. Excessive expression by either method is dysfunctional. Adults with ADHD may well express anger both ways. They may have a “short fuse,” meaning they quickly respond with anger in the face of minimal provocation (as was the case for Michael), or they may build up frustration over a long period of time (as was the case for Jane). Individuals with A D H D may vent their frustration and angry feelings by lashing out at others (both strangers and loved ones) and/or by damaging property. Their difficulty with stress intolerance was one of the first symp- toms described to differentiate between children and adults with ADHD (Bellak, 1979). Loved ones may feel they are walking a tight rope.

Within the therapeutic environment, the distinc- tion between escalating anger and bottling up anger should be explored. The therapist should always be cautious when treating volatile individ- uals who may well overrespond in the face of per- ceived threat. However, when appropriate the most effective intervention is likely to be achieved when the therapist models the dysfunctional ex- pression of anger and the client role-plays the ap- propriate expression of anger with the therapist. Various methods of appropriately managing anger should be introduced into the therapy (e.g.,

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talking problems over with friends; walking away from provocation; cognitively restructuring an event). However, individuals with A D H D may not have the available social support to draw on for personal problems. Most people can talk things over with someone or seek out advice, but people with ADHD may not have developed a social net- work to draw on in this respect. Often, close ques- tioning about social relationships reveals that a nominated “best friend” is the equivalent of an acquaintance by normal standards. In such cases clients need to be wary about revealing thoughts and attributions to acquaintances because this may be perceived as overfamiliarity and may be thus met with rejection.

It is important for the therapist to acknowledge the clients’ feelings of deep distress and emotional turmoil. This will be especially important when inviting them to cognitively reframe a situation. Individuals with ADHD have often learned that the world may be a threatening place and that people are unkind or even hostile. It may not be easy to encourage the client to take a different per- spective in the face of challenging situations. Clients should be taught to stop and think (e.g., control the impulse to jump to a conclusion about underlying intent). Negative automatic thoughts are likely to be “people hate me” and “people provoke me.” These cognitive distortions should be challenged and alternative perspectives generated (e.g., the person may have a lot on his mind, have personal problems, and/or be exceptionally busy). Thus the client makes fewer personal attributions in favor of more general attributions. It will be important that clients are taught to self-monitor and regulate their emotions, identifying the point at which they start to become overaroused and need to engage in a counterstrategy. Specific methods can be taught to interrupt the dysfunctional cognitive process, such as distractive techniques like mental arithmetic (i.e., counting backwards from 500 by subtracting 7). It may be difficult to apply the techniques learned in therapy to situations in the outside world. When aroused, people often become less rational and

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erence to long-distance driving work. In this type of work he was largely self-employed and relatively autonomous in the organization of his day. Michael said he never became bored with the work because he found stimulation in the changing scenery. No two days were the same.

Michael’s adaptive lifestyle meant, however, that he spent long periods alone on the road. He avoided social interaction and the development of social relationships. In such cases individuals with ADHD may possess inadequate and/or underdeve- loped social skills. They certainly appear to display difficulties in the production of appropriate social behavior and tend to show disproportionate rates of socially noxious behavior. Empirical studies, however, suggest that there are few deficiencies in rates of social interactions, in social cognitive problem-solving skills, or in their ability to perceive social situations accurately (Whalen & Henker,

1985, 1992). It may be that people with ADHD have difficulty modifying social behavior in acc- ordance with shifting situational demands. Hyper- active youngsters tend to persist in social roles calling for assertion and dominance even when the situation shifts to call for more deferent or accommodating behavior (Grenell, Glass, & Katz, 1987; Landau & Milich, 1988; Whalen, Henker, Collins, McAuliffe & Vaux, 1979). They may pos- sess social agendas that differ from those of their peers (e.g., by valuing sensation-seeking or social disruption at the expense of smooth interaction as desired goals). Appropriate goals of therapy there- fore need to be determined and agreed on at the outset.

It is possible that an attention deficit causes indi- vidualstobeslowtorecognizevitalsocialcues.They have inadequate knowledge of social rules, roles, and routines (Landau & Milich, 1988; Whalen & Henker, 1992).They may be deviant in their under- standing of the fundamental “rules” of friendship patterns and social interaction. For Michael, initi- ation of friendships was less problematic than the maintenance of friendships. He was also poor at negotiating interpersonal conflict. His impulsive

forget to apply learned coping mechanisms. Michael found it helpful to keep a card on which he listed useful strategies generated in therapy to help him remain calm when feeling provoked. He carried this card with him so that if he found himself in a situation he could not cope with, he was able to refer to the card and adopt some of the strategies, as opposed to “going blank” and feeling helpless and unable to control his anger and rage.

Interpersonal Skills

It may be that adults with ADHD are unaware of the impact of their behavior on others, with cogni- tive deficits causing them to misappraise social situ- ations. There is evidence that their self-report lacks validity when reporting interpersonal relationship problems in the family setting (Barkley, Fischer, Edelbrock & Smallish, 1991). Adults with A D H D frequently report difficulties interacting with others and maintaining relationships. This may stem from an underlying problem in communication skills. An adult with ADHD may not perform well in situ- ations that demand rapid shifts in style or topic of conversation. This may be especially apparent in small-group environments. Inattention and dis- tractibility may be perceived by others as an inabil- ity to listen or as a lack of interest. Impulsivity may be interpreted as rudeness if a person makes un- timely and inappropriate interruptions to conversa- tion. Failure to follow instructions, mood swings, and an unpredictable temperament may be per- ceived by others as obnoxious behavior, and indi- viduals may ultimately become ostracized socially and/or withdraw from social situations. This was the case for Michael. Work colleagues viewed him as unable to participate on a team. He did not act appropriately with authority figures, such as his managers, because he would not accept direction and advice, saying he would not be “told what to do.” Michael solved the problem by adapting his occupational environment to meet his needs. He withdrew from forms of employment defined by a linearly structured line-management format in pref-

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and restless nature meant he engaged in limited ac- tivity with peers to whom he most likely appeared distracted and unfocused as he constantly moved on sharply to new stimuli. These are common social problems for ADHD adults, who in turn are viewed by others as unreliable and fickle.

Social skills training aims to equip the individual with the behavioral responses necessary for success- ful outcomes in social situations. For adults with ADHD, therapy needs to focus on both microskills (e.g., maintaining eye contact, appropriate voice volume and tone, body positioning) as well as ma- croskills (e.g., giving compliments and constructive feedback, turn-taking and listening skills). An im- portant issue is likely to be the misinterpretation of social cues. Individuals should be taught basic social perception skills enabling them to recognize and engage in appropriate social behavior. This can be achieved by role-playing familiar social circumstances and modeling an appropriate re- sponse.

Anxiety

Worry, as well as clinical anxiety, is a frequent comorbid problem for adults with A D H D (for review see Chapter 2 in this book). Individuals like Anne may develop social phobia in addition to generalized anxiety, resulting in avoidance of anxiety-provoking situations. Such individuals may well have had extensive prior contact with mental health services for their comorbid prob- lems, which may have been considered primary, so their underlying attention deficit disorder would have gone unrecognized and untreated. Therapy should aim to reduce anxiety by teaching individuals how to identify, evaluate, control, and modify their negative, danger-related thoughts and associated behaviors. This will include giving infor- mation about the model of anxiety and the rela- tionship between thoughts, feelings, and behavior. If appropriate, the cognitive model of panic should also be explained, setting out how individuals tend to interpret a range of bodily sensations in a cata-

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strophic way. Anne found it difficult to believe at first that she could experience such debilitating physical symptomatology from a psychological phenomenon. Gradually, however, she began to accept the possibility. This was achieved through hypothesis testing and the accumulation of evi- dence-based information collected from set home- work tasks. Anne practiced progressive relaxation techniques and introduced relaxation into her daily routine. Shelearnedtoidentifyearlysignsofanxiety and to apply the learned cognitive-behavioral tech- niques to reduce anxious feelings.

Cognitive-behavioral therapy is therefore very appropriate for adults with ADHD whose primary motivation is immediate gratification. The therap- ist should set up immediate, small, achievable goals, so achievement is reinforced by success. A graded hierarchy of anxiety-provoking situations should be determined by the individual and, starting with the least threatening (and most achievable), the therapist should use these in home- work tasks. Individuals should be encouraged to keep a diary of their thoughts and feelings when attempting to complete homework tasks; through the diary, clients can be helped to identify negative thoughts. These are errors in processing through which perceptions and interpretations of experi- ence become distorted. For example, Anne thought people were looking at her and thinking “she’s stupid.” They can then learn that they can control their feelings of anxiety by employing various dis- traction techniques and/or cognitive challenges of automatic and irrational thoughts (Therapist: “What is the evidence that those two men in the bar thought you were stupid?”). Eventually, through exposure to feared situations, Anne learned to cope with her feelings of anxiety and to exercise control over them.

Common thinking distortions for adults with ADHD are that they tend to think in all-or-nothing terms, complicated by the fact that they make snap decisions and jump to conclusions. Thus if some- thing does not immediately go very well (and often on the first attempt), then they give up and do not

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experiences, focusing only on the negative and not viewing things from a positive perspective. When depressed, adults with A D H D may be at greater risk for attempting suicide due to poor impulse control. Thus they may struggle to inhibit the impulse to act out a suicidal ideation (Brent, Perper, Goldstein, et al., 1988).

A positive reward system should be set up that represents an “immediate” reward system, for adults with ADHD are unlikely to delay positive reinforcement for long periods. For example, “If I finish the daily household chores each day for the entire week, then I’ll go swimming on the weekend” is unlikely to gratify adults with ADHD who favor immediate small rewards over a single longer-term and greater reward. A more immediate reward, such as telephoning a friend that evening, is likely to offer greater incentive. It is important that re- ward be matched to reflect value to the individual. Activity scheduling may be helpful. Jane found that intense periods of stimulation served as a reward for the completion of mundane tasks, espe- cially because this represented time out from her family for herself. A daily schedule or timetable was structured so as to intersperse regular periods of high stimulation (such as physical activity) in order to avoid boredom and distractibility.

Group Therapy

Adults with ADHD may feel socially isolated and misunderstood by others. A group forum pro- vides the opportunity to meet people with similar problems. The psychological interventions dis- cussed in this chapter are described elsewhere as efficacious when offered in a group format (Mor- gan, 2000). Many adults with A D H D have never had contact with fellow A D H D sufferers. A group format therefore offers the opportunity to share information and to learn how others cope with their difficulties. Individuals are likely to feel less isolated and alone. The group provides a support- ive environment for acquiring and rehearsing key

try again. They may also make negative interpret- ations, even though there are no definite facts. Thus they become “mindreaders” predicting the outcome of events. Another common distortion is that they set unrealistic or unobtainable standards for themselves and become anxious when they are unable to achieve them. Adults with ADHD often possess an awareness that they are underperform- ing relative to their potential. In response, they may set unrealistic goals. Efforts to assist in breaking larger goals into smaller steps may be resisted and viewed as menial. In these situations individuals may perceive that they are being treated as “stupid” by the therapist, unwittingly reinforcing a negative underlying assumption.

Depression

A longstanding history of internalized failure combined with a tendency to self-regulate and overmonitor performance is likely to result in low self-esteemand demoralization, anticipated failure, poor self-confidence, and feeling misunderstood by others. Low self-esteem affects not only self-per- ception and self-image but the ability to succeed in our achievement-oriented society. The cognitive model of depression should be explained to the individual, because developing a practical under- standing of problems is likely to facilitate the indi- vidual’s ability to overcome them. A problem list should be generated that categorizes various prob- lems (e.g., poor self-expression, feelings of inferior- ity, symptoms of depression). This can be used to focus on specific problems collaboratively. A daily diary of thoughts and feelings will help to identify such problems. Homework assignments should be set for between sessions (and follow logically from each session). These should have a self-help and motivating focus. Once the individual has learned to identify negative automatic thoughts, he or she can be taught to challenge them.

Common underlying schemas are “I can’t cope” and “I’m useless.’’ Individuals with ADHD may tend to catastrophize or overexaggerate negative

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skills such as communication and anger and stress management. Group CBT treatment usually inclu- des approximately ten individuals. It has a time- limited, semistructured format with target goals and themes for each session. Optimally, the group should balance didactic instruction with time for open-ended discussion.

Weekly sessions, however, whether individual or group, may not be the optimum format for adults with ADHD, due to significant problems with or- ganization and time management. Adults with ADHD are likely to have difficulty making a regu- lar commitment to a therapeutic process they per- ceive as lengthy and drawn out, thus not satisfying their desire for immediate gratification. In order to avoid client disengagement, therapists should consider capitalizing on the individual’s natural enthusiasm by organizing one-day group therapy work shops. This format is very attractive to indi- viduals with A D H D because they offer an inten- sive, interactive environment that is perceived to be fast-track learning and that requires minimal com- mitment. Topics can include all those described in this chapter, but can also be extended to include medication issues, decision making, stress reduc- tion, work/vocational issues, and the development of personal coping strategies. These could be offered in the form of a progressive series of group therapy workshops, starting with an introductory “Living with ADHD.”

CONCLUSIONS

This chapter has proposed a cognitive-behav- ioral model of psychotherapy for adults with ADHD that emphasizes the importance of invok- ing change from the outside in (change the environ- ment) as well as change from the inside out (change the individual). Historically, treatment for ADHD has been predominantly stimulant medication, but long-term prognosis and adaptive functioning are likely to improve with psychological therapy. A variety of techniques may be adapted to match

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individual needs. An important component, how- ever, must be an educative factor in order that family members, as well as the affected individual, develop an understanding of the disabling effects of ADHD in addition to its long-term implica- tions. This information is likely to facilitate the development of appropriate, realistic expectations for behavior and potential achievement. Pragmatic cognitive-behavioral therapy is likely to be the most effective therapeutic model because it focuses on the development of self-management skills. And CBT can be applied within either a one-to-one or a group setting. One-day group workshops are likely to be especially attractive to clients with ADHD because they represent fast-track learning and treatment.

The therapy required will be determined not only by an individual’s presentation but also by his or her sex, age, and place in the life course. An important determining factor of treatment out- come is likely to be whether ADHD was identified and treated in childhood or whether it was missed or misdiagnosed in childhood and not identified until adulthood. In the latter case, individuals may feel resentment and anger toward “the system” and their clinical care providers. The therapist needs to be aware that a potential outcome of treatment is that the client become more reflective, resulting in increased rumination over life’s failures. The risk of depression may increase. Adults with A D H D in partial remission and ADHD “graduates” should not be dismissed with their remitting sympotmatol- ogy. They may well have much to contend with ~ maladaptive coping strategies, anticipated failure, poor self-confidence,low self-efficacy,and negative core beliefs about themselves, other people, and the world.

Finally, adults with ADHD have many strengths that should always be emphasized and applied therapeutically. With help, they have choice and opportunity to develop these talents and adapt the environment to suit their personal needs. What they often lack is the vision and courage to doso.

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achieve academically and socially. Roger ended the relationship when he met someone else. Anne knew this person and perceived her to be confident and outgoing. Anne felt rejected and worthless, and her self-worth became a measure of how other people perceived her. To Anne this meant she had to be perfect. Whenever she had to go anywhere, she would leave hours before her appointment time in order to ensure that she arrived at the correct place and on time. This meant that she frequently arrived early at her location. She would while away time in coffee bars.

Anne had a memory of being in one coffee bar when two young men kept looking at her and smiling. One of them offered to buy her a coffee. She could remember getting very red in the face and feeling very stupid. Her cognitions were that the men must know that she is stupid and that they were offering to buy her a coffee because they felt sorry for her. After that Anne became increasingly uncomfortable whenever she went into coffee bars. If anyone looked at her, especially if they were young men, her hands would start to shake and she became frightened that she would spill her coffee. A few months later, when out with friends in a bar, she had a similar experience when a man she did not know started to talk to her. Anne started to avoid using long-stemmed wine glasses because she was afraid she would spill the contents. This later became a problem in restaurants, espe- cially if they were brightly lit when her hands would start to shake and she would feel that she could not breathe.

On several occasions she had such extreme feel- ings of panic that she left the social event and went home. Eventually Anne realized that she needed help with her social phobia and sought help. Within the therapy she identified her under- lying negative schemas as “I am unlovable” and “I am stupid.” These stemmed from her early child- hood experiences of getting things wrong in school and her peer relationship problems. Anne believed that no man could ever love someone so stupid.

Anne

APPENDIX Vignettes

I met Anne, an attractive young woman, when she was 28 years old. She suffered with ADHD and comorbid anxiety. As a child she succeeded rela- tively well academically, probably reflecting that she was not educated in a mainstream school but in the private sector, which provides smaller class sizes, more structure, and individual one-to-one tuition. Nevertheless, Anne believed she was iden- tified by teachers as more vulnerable than her peers and as requiring more attention and support in her academic work. Teachers said that she had the potential but that she was lazy and unmotivated to complete school work. Anne said she tried very hard but something always went wrong. Either she did not understand the basic concepts, or she would find it difficult to study for long periods of time. Sometimes she would forget what she had to do, and she frequently lost relevant school books and materials. She recalled feeling humili- ated when she would turn up at the wrong class- room because she had gotten mixed up about where she should be.

Anne became very anxious over her inability to get things right; the more she tried, the more every- thing seemed to go wrong. She described experi- encing panic attacks from the age of 12years. Anne was bullied by her peers, who called her names such as “stupid” and “backward.” She recalled spend- ing a lot of time in the playground feeling lonely and watching the children play. She recalled always being the last to be chosen for team sports. Al- though she struggled with academic work, Anne worked hard and left school with average grades and went to university.

It was at university that she met Roger, her first boyfriend. They dated for about two years, and at this stage in her life Anne reported beginning to feel more settled. She felt she had the potential to

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Peter

I first met Peter when he was 20 years old. He was diagnosed with ADHD and antisocial personality disorder. He was born and brought up in London and was one of three children. His parents separated when he was 4 years old and resulting in sporadic contact with his father. As a child he was hyper- active, disruptive, and conduct disordered. When he was 7 years old, he was seen by an educational psychologistontwooccasionsforhisbehavior.Peter was educated at a special school for children with behavioral difficulties.In later years he missed a lot of schooling through truancy. Peter was expelled from four schools due to his behavioral problems and eventually left school when 14years old, with no qualifications. He had never been employed.

Peter had a history of contact with the police from the age of 12 years. He had approximately 50 convictions, most involving impulsive acts of theft (usually alone), criminal damage, and possession of class B drugs. His criminal behavior was usually opportunistic and not well thought out or planned. He had been a polydrug user since the age of 14 years and tended to offend to fund his drug habit. He had spent a significant proportion of his youth and young adulthood in young offenders’institutes or prison, usually for stays of a few months in duration. As a child and as an adult he had signifi- cant problems with interpersonal relationships. He had no longstanding friends because he believed that people would let him down if he got too close to them. He said he found it difficult to trust people. In later years, he saw his mother rarely and reported having a poor relationship with her.

Peter was very difficult to engage, and he was unreliable in his clinic attendance. A pattern de- veloped whereby he would comply with medication when in prison but disengage once in the commu- nity. Eventually he received a five-year prison sen- tence and started to take stimulant medication regularly. His medical officer noted a significant decrease in his aggressive and oppositional behav- ior and an increase in his ability to concentrate and

control his impulses. He was described as being calmer and more manageable. Peter’s motivation and self-esteem improved to the point that, with encouragement, he was participating in further edu- cation classes and was making progress in a literacy class. Peter also attended art therapy sessions, and his artistic talent was such that it was felt that a long-term goal would be to enroll him in a Art Foundation University course.

A striking aspect was his developing insight into his cognitive and hyperactive behavioral problems. He said that at first he had felt very angry that, despite having had numerous contacts with child andadolescentservices,hisADHDhadbeenmissed. His improved concentration, lower threshold of dis- tractibility, and better impulse control, however, led him to ruminate and think about how different his life might have been had his problems been better recognized in childhood. He contemplated his broken relationship with his mother and his dysfunc- tional upbringing. It was felt that he was at risk for becoming depressed and that he required individual therapy to help him adjust to the changes in his personal functioning, how he saw himself, and how he saw the world in a different way. The interactions of others became more positive toward him, and his problems were better understood by those around him. In the course of his psychotherapy Peter de- veloped better insight into his psychological prob- lems and substance dependency. He expressed concern that he would again abuse street drugs when in the community, and it was arranged for him to attend substance-misuse group therapy ses- sions. Rehabilitation became possible within a shorter time than expected.

Jane

Jane is 35 years old. She is a mother with ADHD with two children with ADHD, boys ages 9 and 7 years. Her ADHD was diagnosed and treated in adulthood when the clinicians involved in her chil- dren~c’are noticed that she also had ADHD symp- tomatology. Jane would frequently be late for

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local church hall. She started to structure her time better by making a week-ahead plan and then gener- ating a list of priorities. These techniques helped Jane to impose order in her day, and this helped her feel more in control and able to cope. She started to use a diary that she kept in her handbag, as opposed to jotting rushed, illegible notes on pieces of paper that were eventually lost. This meant that she began to settle bills on time (twice her telephone had been disconnected for nonpayment), and the children had the appropriate items required for school on the correct day (such as sportswear). Jane interspersed her day with frequent periods of reward. These ranged from small rewards, such as a short rest over a cup of tea, to larger rewards, such as half hour to read a magazine or book.

Michael

When I met Michael he was 38 years old, di- vorced, and with no children. He was a proud man who tended to deny his problems and painful emo- tions. Although he had suffered all his life with ADHD symptomatology, he had no idea that these were problems that could be diagnosed and treated. His mother told me that by age 3 he was frequently involved in reckless and dangerous es- capades, such as climbing out of windows and disappearing from the house. He was referred to a child psychologist when he was 6 years of age for disruptive behavioral problems. As is the case for most children with ADHD, he had struggled in school and was expelled from two schools for dis- ruptive and oppositional behavior. He could not read or write until he was 8 years old. It was not until he attended a special school for children with learning and behavioral problems, with smaller class sizes and greater structure, that he began to progress academically.

Michael left school at 16 without taking any formal examinations. He had difficulty settling into any particular employment and tended to work in temporary unskilled agency work (e.g., laboring, warehousing, driving, retail, lifeguard,

appointments with pediatricians, and sometimes she would turn up on the wrong day. She seemed to have difficulty following instructions and advice and would frequently lose track of the conversation. She was objectively observed to be restless, and she seemed to be overly rapid in her behavior, making careless mistakes. Jane often felt exhausted and drained by her sons, who learned that there were wide differences between their parents in terms of boundary setting. Their father, Jack, was very con- sistent and set clear boundaries, whereas their mother was very inconsistent in her management of the children. She was volatile, haphazard, and dis- organized, and her mood swings determined her parenting style. For example, sometimes Jane would allow the children to stay up late at night watching television and playing in their bedrooms. Other times she made them go to bed very early. Jack, who worked a night shift, was very clear and con- sistent in what they could and could not do in the day time. The children generally obeyed Jack but were challenging and oppositional toward their mother.

Jane often experienced feelings of anger and frustration, and she would vent her feelings on Jack and the children. She often felt that she could not cope. Her relationship with Jack became increas- ingly strained, and they frequently argued over the children. Family therapy initially helped the couple examine their different parenting styles and the impact these had on their children. Gradually Jane learned to be firmer in her boundary setting with the children and to be more consistent. It was important to Jane to have her feelings of frustra- tion and helplessness acknowledged, for she had always felt like the least important person of the family, who simply provided for everyone else’s needs. Diagnosis and treatment with stimulant medication of her ADHD meant that she was able to focus on her own difficulties and put those into context with her relationship with her family.

With therapeutic support, Jane set aside “time out” for herself on a daily basis. She organized for Jack to have the children for an hour before he went to work while she did aerobics with a neighbor in her

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catering). Michael was of average intelligence and perceived this work to be beneath his abilities. He become quickly bored and was either fired or left jobs when he fell out with line management because he “did not need to be told what to do when employed in menial tasks.” Psychosocially Michael had been an aggressive child who did not relate well to same-age peers. In adulthood he was fre- quently involved in verbal altercations with friends, acquaintances, and work colleagues. He was chal- lenging toward others, which made him lose friend- ships. When unemployed he became frustrated, bored, and depressed. He had feelings of useless- ness and inferiority.

Michael had a low threshold for boredom, re- quiring employment that offered him high stimula- tion, frequent opportunity for positive feedback, and immediate gratification. Such employment was difficult to find, especially for someone with no qualifications and a poor job record. Michael took a tractor trailer driving course when he was 29 years old. He enjoyed driving because it offered greater stimulation and responsibility, since he was not in the same environment all day and every day, and he had the opportunity to structure his time according to his needs. With driving, Michael suc- cessfully adapted his working environment to meet his needs. For example, he was able to make fre- quent stops at different places; driving on the Euro- pean continent offered changing scenery; to a certain extent he could manage his own time and structure his day; he could vary his routes; different

jobs and destinations offered relief from monotony and boredom, and he did not have to relate to line management or colleagues on a daily basis.

Six years later, he sustained a serious knee injury, making it unlikely that he would be able to continue vocational driving for much longer. Al- ternative working opportunities were limited by his age and his untreated ADHD; e.g., he was unable to take a job operating machinery because this might endanger himself or others. Michael’s self- esteem and confidence were closely related to his occupation, which represented one of the few areas

Susan Young

in which he had achieved and succeeded in life. He required psychological therapy to help him with impulse control and to adjust to a significant change in occupational status. It became an im- portant factor in preventing him from becoming depressed. Therapy also focused on the develop- ment of interpersonal relationship skills, anger management techniques, time management, and organization skills.

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Barkley, R. A,, Fischer, M., Edelbrock, C., & Smallish, L. (1991). The adolescent outcome of hyperactive children diag- nosed by research criteria- 111.Mother-child interactions, family conflicts and maternal psychopathology. Journal of Child Psychology and Psychiatry, 32(2), 233-255.

Bellak, L. (1979). Psychiatric aspects of minimal brain dysfunc- tion in adults. New York: Grune and Stratton.

Berry, C. A,, Shaywitz, S. E., & Shaywitz, B. A. (1985). Girls with attention deficit disorder: A silent minority? A report on behavioral and cognitive characteristics. Pediatrics, 76, 801-809.

Biederman, J., Faraone, S. V., & Chen, W. J. (1993). Social Adjustment Inventory for Children and Adolescents: Con- current validity in ADHD children. Journal of American Academy of Child and Adolescent Psychiatry, 32(5), 1059-

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Biederman, J., Faraone, S., & Mick, E. (1999). Clinical correl- ates of ADHD in females.Journal ofthe American Academy of Child and Adolescent Psychiatry, 38, 966-975.

Brent, D. A,, Perper, J. A,, Goldstein, C. E., et al. (1988). Risk factors for adolescent suicide victims with suicidal inpatients. Archives ofGenera1 Psychiatry, 45, 581-588.

Ernst, M., Liebenauer, L. L., King, C., Fitzgerald, G. A,, Cohen, E. A,, & Zametkin, A. J. (1994). Reduced brain metabolism in hyperactive girls. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 858-868.

Goldstein, S. (1997). Managing attention and learning disorders in late adolescence and adulthood: A guide for practitioners. New York: Wiley.

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disorder boys from aggressioddefiance scores. Journal of American Academy of Child & Adolescent Psychiatry, 33, 185-1 90.

Solden, S. (1995). Women with attention deficit disorder: Embra- cing disorganization at home and in the workplace. Grass Valley, CA: Underwood Books.

Swanson, J. M., Sergeant, J. A,, Taylor, E., Sonuga-Barke, E. J. S., Jensen, P. S., & Cantwell, D . P. (1998). Attention-deficit hyperactivity disorder and hyperkinetic disorder. The Lancet, 351, 429433.

Weiss, G., & Hechtman, L. (1986). Hyperactive children grown up: Empirical findings and theoretical considerations. New York: Guildford Press.

Whalen, C. K., & Henker, B. (1985). The social worlds of hyperactive (ADDH) children. Clinical Psychology Review, 5,447-478.

Whalen, C. K., & Henker, B. (1992). The social profile of attention-deficit hyperactivity disorder: Five fundamental facets. Child and Adolescent Psychiatric Clinics of North America, I , 395-410.

Whalen, C. K., Henker, B., Collins, B. E., McAuliffe, S., & Vaux, A. (1979). Peer interaction in a structured communi- cation task: Comparisons of normal and hyperactive boys and of methylphenidate (Ritalin) and placebo effects. Child Development, 50, 388-401.

Young , S. J. (1999). Psychological therapy for adults with attention deficit hyperactivity disorder. Counseling Psych- ology Quarterly, 12(2), 183-190.

Young, S. J. (2000). ADHD children grown up: An empirical review. Counselling Psychology Quarterly, 13(2), 1-10,

Young, S. J., & Harty, M. A. (2001). Treatment issues in a personality-disordered offender: A case of attention deficit hyperactivity disorder in secure psychiatric services. Journal ofForensic Psychiatry, 12, 158-167.

Young, S. J., Toone, B., & Tyson, C. (2001). Comorbidity and psychosocial profile of adults with attention deficit hyper- activity disorder manuscript submitted for publication.

Zametkin, A. J., Karoum, G., Rapoport, J. L., et al. (1984). Phenylethylamine excretion in attention deficit disorder. Journal of the American Academy of Child Psychiatry, 23, 310-3 14.

Grenell, M. M., Glass, C. R., & Katz, K. S. (1987). Hyperactive children and peer interaction: Knowledge and performance of social skills. Journal ofAbnorma1 Child Psychology, 15(1), 1-13.

Hechtman, L., & Weiss, G. (1986). Controlled prospective fif- teen-year follow-up of hyperactives as adults: Non-medical drug and alcohol use and anti-social behavior, Canadian Journal of Psychiatry, 31, 557-567.

Heptinstall, E., & Taylor, E. (1996). Sex differences and their significance.In S. Sandbury (ed.). Hyperactivity Disorders of Childhood. Cambridge University Press. New York.

Hill, J. C., & Schoener, E. P. (1996). Age-dependent decline of attention deficit hyperactivity disorder. American Journal of Psychiatry, 153(9), 1143-1 146.

James,A,,&Taylor,E.(1990).Sexdifferencesinthehyperkin- etic syndrome of childhood. Journal of Child Psychology and Psychiatry, 31, 437-446.

Kashani, J., Chapel, J. L., Ellis, J., & Shekim, W. 0 . (1979). Hyperactive girls. Journal of Operational Psychiatry, 10(2), 145-148.

Landau, S.,&Milich,R.(1988).Socialcommunicationpatterns of attention-deficit-disordered boys. Journal of Abnormal Child Psychology, 16, 69-81.

Lomas, B., & Gartside, P. (1999). ADHD in adult psychiatric outpatients. Psychiatric Services, 5, 705-717.

Mannuzza, S., Klein, R. G., Bessler, A,, Malloy, P., & LaPa- dula, M . (1993). Adult outcome of hyperactive boys. Arch- ives of General Psychiatry, 50, 565-576.

Morgan, W. D. (2000).Group treatment of adults with ADHD. In J. White & F. Freeman (Eds.). Cognitive behavioralgroup treatment with specific problems and populations. Washing- ton, DC: American Psychological Association Books. (pp. 227-248).

Nadeau, K., Quinn, P., & Littman, E. (2000). Understanding girls with AD/HD. : Advantage Books.

Satterfield, J. H., Hoppe, C. M., & Schell, A. M. (1982), A prospective study of delinquency in 110 adolescent boys with attention deficit disorder and 88 normal adolescent boys. American Journal ofPsychiatry, 139(6), 795-798.

Satterfield,T.,Swanson,J.,Schell,A,,&Lee,F.(1994).Predic- tion of antisocial behavior in attention-deficit hyperactivity

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Pharmacotherapy of Adult ADHD

Jefferson B. Prince, M.D., Timothy E. Wilens, M.D.

INTRODUCTION

Originally conceptualized as a disorder of child- hood (Laufer, Denhoff, & Solomons, 1957), atten- tion deficit hyperactivity disorder (ADHD) is increasingly recognized in adults. A D H D is esti- mated to affect 2-9% of school-age children and up to 5% of adults (Bauermeister, Canino, & Bird,

1994;K. Murphy & Barkley, 1996).Although some investigators question the persistence of A D H D in adulthood (Hill & Schoener, 1996), long-term con- trolled follow-up studies of young adults diagnosed with ADHD in childhood demonstrate persistence of the syndrome in up to 60% (Weiss & Hechtman, 1986; Mannuzza, Klein, Bessler, Malloy, & LaPa- dula, 1993). While some clinicians remain skeptical of adult A D H D (Shaffer, 1994), evidence supports the descriptive, face, predictive, and concurrent Val- idity of the syndrome in adults (Spencer, Bieder- man, Wilens, Faraone, & Li, 1994; Spencer, Biederman, Wilens, & Faraone, 1998a). Adults with A D H D present with a developmental deriv- ation of symptoms similar to those of children, notably inattentioddistractibility followed by hyperactivity-impulsivity. Comorbidity with mood,

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anxiety, substance use, and antisocial disorders are common in adults with ADHD.

Like children, pharmacotherapy is a mainstay of treatment for ADHD in adults. Despite the large amount of data on pharmacotherapy of ADHD in children, there is a limited number of medication studies in adults with the disorder. Most controlled investigations in adults with A D H D have studied the stimulants. As with children, there tends to be a dose-related improvement in A D H D symptoms with the stimulant medications in adults. This litera- ture supports the stimulants as the most effective available treatment for ADHD symptoms in adults. Several nonstimulant alternatives have been investi- gated. Although these data are limited, medications with catecholaminergic activity appear to have efficacy, whereas those with predominately seroto- nergic properties appear ineffective in the treatment ofcoreADHDsymptomology.Incaseswithpsychi- atric comorbidity, residual symptoms, or adverse effects, clinical experience, coupled with a small lit- erature, supports combining medications, such as the stimulants and antidepressants. Often, cogni- tivelbehavioral-based psychotherapies are necessary in conjunction with medication in order to fully

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address executive function deficits, dynamic issues (within individual and family), residual symptom- atology, as well as comorbid psychopathology in ad- ults with ADHD. Future controlled studies applying stringent diagnostic criteria and outcome method- ologyarenecessarytoenhancetherangeofpharma- cotherapeutic options for adults with ADHD.

OVERVIEW OF THE NEUROBIOLOGYAND GENETICS OF ADHD

The Neurobiology and genetics of ADHD in- cludes the following characteristics.

Highly familial disorder with heritability estimated to be 0.8
Primary disturbance of catecholamine neurotransmission

Anterior cingulate, frontal cortex, basal ganglia, corpus callosum, and cerebellum manifest decreased size in ADHD
Variations in genes that code for dopamine transporter protein (DAT) and dopamine D4 receptor (DRD4) associated with distinct ADHD subtypes

No current role for neuroimaging or genetic testing in diagnosis of ADHD in clinical practice (but stay tuned)

The pharmacotherapy of ADHD is related directly to our understanding of its the pathophy- siology. Although the exact neural and pathophy- siological substrate remain unknown, an emerging neuropsychological and neuroimaging literature supports our understanding of ADHD as a disorder involving dysregulation of the frontal networks and/ or frontostriatal dysfunction. The neurochemical dysfunction in ADHD appears to be mediated by dopaminergic and adrenergic systems, with little direct influenceby the serotonergic systems(Zamet- kin & Liotta, 1998). Stimulants, the most effective treatment for ADHD, block the reuptake of dopa- mine and norepinephrine presynaptically and simul- taneously increase the release of these monoamines

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into the extraneuronal space (Elia et al., 1990; Wilens & Spencer, 1998, 2000). Similar pharamco- dynamic effects are reported with those antidepres- sants (tricyclic antidepressants and bupropion) effective for ADHD. While recent reports using data from animal models speculate on a role for serotonin in the pathophysiology of A D H D (Quist & Kennedy, 200l), serotonergic dysregulation does not appear integral in the pathophysiology of ADHD. Additionally, medications, which increase serotonin, have not been shown to be useful for core A D H D symptomatology. Although cholinergic modulation of temporal memory has been investi- gated (Meck & Church, 1987), the effects of choli- nergic-enhancing agents on ADHD, as well as dopaminergic and other neurotransmitter systems, are currently under investigation (Wilens, Bieder- man, Wong, Spencer, & Prince, 2000; De Fockert, Rees, Frith, and Lavie, 2001). Regions of the brain, including the anterior cingulate, frontal cortex, basal ganglia, corpus callosum, and cerebellum, all show diminished size when individuals with A D H D are compared to individuals without the disorder. Similarly, functional-imaging studies in adults with ADHD demonstrate reduced global metabolism in catecholamine-rich areas of the brain (Zametkin & Liotta, 1998).Contributions from family, adoption, and twin studies strongly support the neurobio- logical basis of ADHD and suggest that genetic risk factors are operant in this disorder (Faraone et al., 1992;Faraone, Tsuang, &Twang, 1999).Recent work form molecular genetics focuses on the associ- ation of A D H D with various genes, including rare mutations in the human thyroid receptor+ gene on chromosome 3 (Hauser et al., 1993),the D4 receptor gene on chromosome 11(LaHoste et al., 1996;Far- aone et al., 1999), as well as the dopamine trans- porter gene on chromosome 5 (Cook et al., 1995; Daly, Hawi, Fitzgerald, & Gill, 1998). Conversely, increased density of presynaptic dopamine trans- porter proteins (DATs) has been associated with certain subtypes of ADHD, especially in patients with significant hyperactivity and impulsivity (Waldman et al., 1998;Swanson, Flodman, & Ken-

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important personal items, such as keys and work and family projects. They usually avoid tasks that require high levels of concentration and patience, such as balancing a checkbook, filing tax returns, and help- ing children with homework. Projects are often put off until the last minute, at which time they often are highly motivated and are able to hyperfocus. Often these patients are drawn to novel stimuli, usually at the expense of the designated object of their atten- tion. Their boredom or intrusiveness often compro- mises conversations with.25 coworkers, spouses, or children.OthersfrequentlyviewadultswithADHD as either flighty or egotistical. Adults with ADHD seem to have difficulty regulating their attention, which leads to repeated problems as they attempt to manage affairs at work, home, or with friends.

Additionally, these patients report symptoms of impulsivity, impatience, boredom, fidgetiness, and intrusiveness (Millstein, Wilens, Biederman, & Spencer, 1997). These symptoms are often evident in the context of social situations. Frequently, adults with A D H D have long histories of social impair- ment and are often perceived as aloof (because they become easily bored) or as self-centered (because they interrupt or make socially inappropriate com- ments). Others are quite gregarious and talkative, “the life of the party,” almost an adult equivalent of the class clown. Adults with A D H D have a sense of urgency and immediacy to their lives and have little tolerance for frustration, delay, or planning. They are easily irritated while waiting in lines and often make decisions without proper consideration of al- ternatives. Collaboration with others is often a mu- tually frustrating experience. Also, young adults with ADHD experience increased rates of traffic accidents, traffic violations, and license suspen- sions (Barkley, Murphy, & Kwasnik, 1996;Barkley, Murphy, DuPaul, & Bush, in press). Finally, symp- toms of overt hyperactivity may be diminished, for many patients have developed compensatory strat- egies to diminish these symptoms. Recent data sup- port the clinical observation that symptoms of hyperactivity-impulsivity decline over time while symptoms of inattention persist (Biederman, Mick,

nedy, 2000). This increased density of DATs appears to be a trait that is transmittable across generations. Thus, ligands specificfor DATs (e.g., Altropane and TRODAT-1) are being actively investigated. A recent letter describes significantly increased D A T density in a group of six adults with ADHD com- pared to controls. Similarly, Krause et al., using single photon emission tomography (SPECT) with the ligand TRODAT-1, demonstrated increased striatal DAT density in adults with ADHD, which was normalized using methylphenidate (Krause, Dresel, Krausse, Kung, & Tatsch, 2000). These exciting developments have implications for our understanding and identification of various sub- types of ADHD, in the diagnosis of ADHD, and perhaps as an a priori method of identifying the best medication for individual patients. However, at this time the use of genetic testing and neuroima- ging is not necessary in clinical practice.

CLINICALFEATURESOFADHD INADULTS

Adults with A D H D typically present with the following clinical picture:

0 Problems with regulating attention and concentration

0 Disorganization, failure to plan ahead, forgetfulness

0 Poor time management skills
0 Difficulty initiating and completing tasks

0 Difficulties in job, parenting, marriage 0 While adults with A D H D usually can

be relied on to accurately report their symptoms,

additional informants often helpful

Adults with A D H D usually describe symptoms of poor attention, lack of concentration, easy dis- tractibility, shifting activities,daydreaming, and for- getfulness (Millstein, Wilens, Biederman, & Spencer, 1997).They often begin one task and then find them- selves in the middle of several projects. These pati- ents appear to have a poorly developed sense of time and are often harried and late. They lose or misplace

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& Faraone, 2000). Overall, these investigators note that most patients with ADHD continue to struggle with a substantial number of symptoms and a high level of impairment.

Adults with ADHD are thought to have deficits of working memory, as exemplifiedby less ability to attend to, encode, or manipulate information (Seid- man, Biederman, Weber, Hatch, & Faraone, 1998). Such deficits in working memory have recently been shown to decrease the ability to filter out distrac- tions, and may contribute to symptoms of inatten- tion in adults with A D H D (De Fockert et al., 2001). AlthoughlessdefinedwithinADHD,organizational difficultiesand procrastination also appear common.

Like children with ADHD, adults with the dis- order may be stubborn and demoralized and have low self-esteem (Biederman et al., 1993;Biederman, 1998). Relationships with family, friends, and em- ployers are often conflicted,whichmay contribute to high rates of separation and divorce, as well as to the academic and occupational underachievement char- acteristic of these adults (Weiss & Hechtman, 1986; Mannuzza et al., 1993). Compared to their non- A D H D peers, adults with A D H D have increased rates of anxiety, depression, and substance use dis- orders (Weiss & Hechtman, 1986; Biederman et al., 1993; Biederman et al., 1995).

ASSESSMENT AND DIAGNOSIS OF ADHD IN ADULTS

The assessment and diagnosis of ADHD in adults has the following features.

DSM-IV is the gold standard.
Several available scales and available to aid assessment, including the Brown Attention Deficit Disorder Scales, Conners Adult Attention Deficit Scale,DuPaul ADHD Rating Scale, and the Wender Utah Rating Scale.
Recent reports validate the reliability of data collected from adults with ADHD.

Jefferson B. Prince and Timothy E. Wilens

There is a potential for use of neuroimaging and genetic testing to identify certain subtypes of ADHD.
Disentangling comorbidities and associated impairments (e.g., executive functions) are a prime clinical challenge.

ADHD can be diagnosed in adults by carefully querying for developmentally appropriate criteria from the DSM-IV (American Psychiatric Associ- ation, 1994),attending to a childhood onset of symp- toms, persistence through adolescence, and current presence of symptoms as well as impairment. Self- reportscales,suchastheBrown-ADDScale(Brown, 1996) and the DuPaul scale (DuPaul, 1990), may assistintheevaluationandmonitoringofADHDin adults. Recently, the Conners Adult A D H D Rating Scale (CAARS) demonstrated high sensitivity and specificity, with an overall diagnostic efficiency of 85% (Conners, Epstein, & Erhardt, 2000). These instruments have generally sound psychometric properties and may be used to aid in diagnosis as well as to assess treatment response. The Wender Utah Rating Scales may be used to aid diagnosis rather than to monitor treatment (Ward, Wender, & Reimherr, 1993). A variety of issues arise in the assessment and diagnosis of A D H D in adults. First, the appropriate diagnosis of ADHD in adults relies on the accurate recall of childhood symptoms and a reliable account of current symptoms and their impact. Someclinicianshave questioned the reliabil- ity of adults with ADHD to accurately report this information (Shaffer, 1994).Recently, Murphy and Schachar evaluated correlation of symptoms be- tween adults with ADHD and other informants (Murphy & Schachar, 2000). Diagnostic informa- tion is obtained from the patient and, whenever pos- sible, from significant others, such as partners, parents, siblings, and close friends. If ancillary data are not available, information from an adult is ac- ceptable for diagnostic and treatment purposes, be- cause adults with ADHD, as with other disorders, are appropriate reporters of their own condition. Careful attention should be paid to the childhood

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erally not be treated until appropriate addiction treatments have been undertaken and the patient has maintained a drug and alcohol free period. Our experience attempting to treat adults with ADHD and ongoing substance use disorders indicates the necessity of addressing the comorbid substance use first and then reassessing and treating the ADHD. Other concurrent psychiatric disorders also need require evaluation. In subjects with ADHD plus bipolar mood-disorders, for example, the risk of mania needs be addressed and closely monitored during the treatment of the ADHD. In cases such as these, the conservative introduction of anti- A D H D medications along with mood-stabilizing agents should be considered.

Sincelearning disabilities do not respond to phar- macotherapy, it is important to identify such deficits to help define remedial interventions. For instance, this evaluation may assist in the design and imple- mentation of an educational plan for the adult who is consideringreturningtoschool,orserveasanaidfor structuring the current work environment. Appro- priate remedial strategies should be employed to address the morbidity of these factors at work and in school.

GENERAL PRINCIPLES OF PHARMACOTHERAPYOF ADHD IN ADULTS

Despite increased recognition that children with ADHD commonly grow up to be adults with the same disorder, the treatment of this disorder in adults remains under intense study. In addition, complicating the diagnostics and treatment strategy, many adults with ADHD have depressive and anx- iety symptoms as well as histories of drug and alco- hol dependence or abuse (Tarter, McBride, Buonpane, & Schneider, 1977; Eyre, Rounsaville, & Kleber, 1982;Wood, Wender, & Reimherr, 1983; Biederman et al., 1993; Wilens et al., 1995a). Thus, with the increasing recognition of the complex presentation of adults with ADHD, there is a need to develop effectivepharmacotherapeutic strategies.

onset of symptoms, the longitudinal history of the disorder, and a differential diagnosis, including medicalheurological as wellpsychosocial factors contributing to the clinical presentation. Neuro- psychological testing should be used in cases in which learning disabilities are suspected or when learning problems persist in the presence of a treated A D H D adult (Barkley, 1990, 1997, 1998).

Differential Diagnosis

A variety of medical and psychiatric conditions should be considered as part of the evaluation of A D H D within adults. Such conditions include sleep disorders, headaches, visual and auditory dis- orders, seizure disorders, endocrine disorders; hep- atic function; use of illicit substances as well as herbal remedies, impact of concurrent medications on cog- nition (e.g., anticholinergic or antihypertensive medications). Laboratory tests, such as thyroid studies, EEG, baseline EKG, and baseline hepatic function tests, are generally not necessary unless indicated by the patient’s symptoms or family his- tory. Additionally, clinicians should obtain a history of anxiety disorders (including trauma), mood dis- turbances (including bipolar disorder), current and past substance use, aggression and impulse control problems, legalinvolvement, psychosis.In addition, current stresses as well as issues involving the patient’s adherence are important to the overall treatment plan.

Disentangling Comorbidities

InadultswithADHD,issuesofcomorbiditywith learning disabilities and other psychiatric disorders need to be addressed (Biederman et al., 1993, 1995). Since alcohol and drug use disorders are frequently encountered in adults with A D H D (Wilens, Spen- cer, & Biederman, 1995a), a careful history of sub- stance use should be completed. A Patient with ongoing substance abuse or dependence should gen-

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In the following sections, guidelines for pharma- cotherapy will be delineated, the available informa- tion on the use of medications for adult ADHD reviewed, and pharmacologic strategies suggested for the management of A D H D symptoms with ac- companying comorbid conditions.

Pharmacotherapy should be part of a treatment plan in which consideration is given to all aspects of the patient’s life. Hence, it should not be used exclusive of other interventions. The administra- tion of medication to adults with ADHD should be undertaken as a collaborative effort with the patient, with the physician guiding the use and management of efficaciousanti-ADHD agents. The use of medication should follow a careful evalu- ation of the adult, including medical, psychiatric, social, and cognitive assessments.

STIMULANTS IN THE TREATMENT OF ADULTS WITH ADHD

Stimulant treatment of adults with ADHD can be characterized as follows.

0 Stimulants represent the first-line pharamcotherapy for ADHD in adults.

0 The two main types of stimulants, methylphenidate and amphetamine compounds, have different effects and are metabolized differently.

0 Methylphenidate does not show up on urine drug screens.

0 Stimulants are not effective for comorbidities within ADHD.

0 Stimulants generally have few medication interactions (except with MAOIs)

Stimulant medications remain the mainstay treatment in children, adolescents, and adults with ADHD. In comparison to the more than 200 con- trolled studies of stimulant efficacy in pediatric A D H D (Spencer et al., 1996), there are only two open and nine controlled stimulant trials in adults with A D H D (Wood, Reimherr, Wender, & John-

Jefferson B. Prince and Timothy E. Wilens

son, 1976; Wender, Reimherr, & Wood, 1981; Mattes, Boswell, & Oliver, 1984; Gualtieri, Ondru- sek, & Finley, 1985; Wender, Reimherr, Wood, & Ward, 1985a; Shekim, Asarnow, Hess, Zaucha, & Wheeler, 1990b; Spencer et al., 1995; Iaboni, Bou- ffard, Minde, & Hechtman, 1996; Spencer et al., 1999b)(Table 9.1). In contrast to consistent robust responses to stimulants in children and adolescents of approximately 70% (Wilens & Biederman, 1992; Wilens &Spencer, 2000), controlled studies in adults have shown more equivocal responses to stimulants, ranging from25Y0(Mattes et al., 1984)to 78% (Spen- cer et al., 1995a) of adults responding to treatment. Controlled trials of methylphenidate (MPH)) (Wood et al., 1976; Mattes et al., 1984; Gualtieri et al., 1985; Wender et al., 1985a; Spencer et al., 1995a)and mixed amphetamine compound (Adder- all) (Spencer et al., 1999a),demonstrate more robust response compared to pemoline (Wender et al., 1981;Wilens et al., 1996b).At this time there are no available studies in adults of extended-release prep- arations or new delivery systems of methylphenidate or dextroamphetamine .

Variability in the response rate appears to be related to several factors, including the diagnostic criteria utilized to determine ADHD, varying sti- mulant doses, high rates of comorbidity, and differ- ingmethodsofassessingoverallresponse.Dosingof the stimulants, for example, appears to effect out- come. Controlled investigations using higher sti- mulant dosing (> 1.O mg/kg/day) resulted in more robust outcomes (Spencer et al., 1995;Iaboni et al.,

1996) than those using lower stimulant dosing (<0.7mg/kg/day) (Wenderet al., 1981;Matteset al., 1984). In addition, dose-dependent response to stimulants was found in three studies of adults with ADHD (Spencer et al., 1995;Wilens et al., 1997a; Spenceretal.,1999b).Althoughcommonlyused,the utility of dextroamphetamine for ADHD in adults remains unstudied. Although long-term data are generally lacking, preliminary data from one controlled trial of 117 adults suggests that the re- sponse to MPH is sustained at six-month follow-up (Wender et al., 1995).

9. Pharmacotherapyof Adult ADHD

171

Study (year) N Wood 15

et al. (1976)

Total Dose Medication Duration (Weight-corrected)

Response rate

73%

33%

50% (childhood onset) 25%

57%

70% 70%

78% dose relationship

Moderate 61%

70% Response rate

Comments

Dx criteria not well defined, low doses of Pemoline; mild side effects

Dx criteria not well defined, high rates of dysthymia; moderate effects
Moderate rate of comorbidity; mild side effects

68% dysthymia, 22% cyclothymia; mild side effects
Problematic outcome measures

Problematic outcome measures
No plasma level associations; no effect gender or comorbidities Improvement in neuropsych. & anxiety 35% reduction in all symptoms; moderate effects >2mg/kg Dose-response relationship

Wender et al. 51
(1981b) Placebo crossover

Mattes et al. 26
(1984) Placebo crossover

Wender et al. 37
(1985a) Placebo crossover

Gualtieri 8 et al. (1985) Shekimetal. 33 (1990b)

Double blind MPH Placebo crossover
Open MPH

Double blind MPH

Spencer et al. 23
(1995) Placebo crossover

Iaboni et al. 30
(1996) Placebo crossover

Wilens, et al. 42
(1996b) Placebo crossover

Spencer et al. 27
(1996b) Cross over

TOTAL 292

—

TABLE 9.1

Studies of Stimulant Pharmacotherapy in Adult ADHD

Design
Double blind MPH

27mg 0.4mg/kg*

37.5-70mg
(0.5-1 .Omg/kg)* 65mg (0.9mg/kg)*

48 mg (0.7mg/kg)* 43 mg (0.6mg/kg)*

42mg* (0.6mg/kg)*

40mg (0.6mg/kg)*

30-100mg 0.5, 0.75, & 1.0 mg/kg

30-45 mg
(0.6 mg/kg)* 150mg 2mg/kg

30mg BID

4 weeks

4 weeks 6 weeks

6 weeks

5 weeks

2 weeks 8 weeks 7 weeks

4 weeks 10 weeks

7 weeks

2-10 weeks

*Weight-normalized dose using 50th percentile weight for age.

Pharmacokinetic Issues in Stimulant Treatment

Plasma levels of the stimulants have not been shown to correlate with response in ADHD in adults

Open Pemoline

Double blind Pemoline

Double blind MPH

Double blind Pemoline

Double blind Adderall Double blind; MPH,

N = 9; open: N = 2 Adderall, Pemoline

rate of comorbidities; side effects in 30%; apparent dose-response relationship

&
Duration of medication trial includes placebo phase. Abbreviations: MPH = methylphenidate, DX = diagnosis

40me JMPH) Variable Dx not well defined; high

(0.6mg/kg)* 105mg (Pem) (1.5mg/kg)* 30mg BID (ADD)

(Gualtieri, Hicks, Patrick, Schroeder, & Breese, 1984; Spencer et al., 1995). Moreover, comorbidity with ADHD and gender has not been associated with variable response (Spencer et al., 1995;Wilens et al., 1996b); however, sample sizes have not been large enough to adequately address this issue.

172

Jefferson B. Prince and Timothy E. Wilens

Pharmacodynamics of Stimulant Treatment

The effects of the stimulants in the brain are variable. Preclinical studies have shown that the stimulants block the reuptake of dopamine and nor- epinephrine into the presynaptic neuron and that both drugs increase the release of these monoamines into the extraneuronal space (Elia et al., 1990;Wilens & Spencer, 1998).While not entirely sufficient, alter- ations in dopaminergic and noradrenergic function appear necessary for clinical efficacy of the anti- ADHD medications, including the stimulants (Zametkin & Rapoport, 1987).There may be differ- ential responses to the chemically distinct available stimulants because each may have a different mode of action. For example, although methylphenidate (MPH) and amphetamines alter dopamine trans- mission, they appear to have different mechanisms on release of dopamine from neuronal pools (Elia et al., 1990; Wilens & Spencer, 2000). The different mechanisms of actions of the amphetamines may explain why adults not responding to one stimulant may respond favorably to another. Moreover, given the differing mechanism of action, it is empirically reasonable, although unstudied, to consider com- bining methylphenidate with amphetamine in re- fractory patients.

Initiation of Therapy and Dosing Guidelines

Given the limited controlled data on the use of stimulants in adults with ADHD, there are limited data available to guide dosing parameters in this population. FDA guidelines for dosing reflect gen- eral cautiousness and should not be the only guide for clinical practice. For instance, absolute dose limits (in mg) do not adequately consider a patient’s height or weight and may result in under-

dosing. Although adults were not included in the MTA study, many clinicians extrapolate these results in their treatment of adults (Group, 1999). Other clinicians may turn to the Texas Medication Algorithm Project for guidance (Pliszka et al., 2000). Doses should be individually titrated based on therapeutic efficacy and tolerability. The overall clinical picture, taking into account all the vari- ables of the patient’s current presentation, should guide selection of an initial stimulant.

Many patient’s respond equally well to either methylphenidate or amphetamine compounds (Greenhill & Osman, 1999). Treatment should be started with short-acting preparations at the lowest possible dose. Initiation of treatment with once- daily dosing in the morning is advisable until an acceptable response is noted. Treatment generally starts at 5mg of methylphenidate, dextroampheta- mine, or amphetamine compound once daily and is titrated upward every three to five days until an effect is noted or adverse effects emerge. Repeat dosing through the day is dependent on the dur- ation of effectiveness, wear-off, and side effects. Typically, the half-life of the short-acting stimu- lants necessitates at least twice-daily dosing, with the addition of similar or reduced afternoon doses dependent on breakthrough symptoms.

Treatment with stimulants appears to be moving in the direction of longer-acting delivery systems. For instance, the new OROS system found in Con- certa delivers methylphenidate for approximately 8-9 hours and thus has a behavioral life of between

10 and 14hours. Concerta can be initiated at 18mg and increased in weekly increments as tolerated to an effective dose. Typical adult dosing of methyl- phenidate is up to 30mg three to four times daily, amphetamine 15-20 mg three to four times a day, and pemoline 75-225mg daily. If an adult with A D H D symptoms is unresponsive or experiences significant side effects to the initial stimulant, con- sideration of an alternative stimulant or class of agents is recommended.

9. Pharmacotherapyof Adult ADHD

173

dose (Brown, Wynne, & Slimmer, 1984; Kelly, Rapport, & DuPaul, 1988). Studies of stimulants in normotensive adults demonstrate elevations of 4 mm Hg of systolic and diastolic blood pressure as well as increases in heart rate of less than 10 beats per minute (Spencer et al., 1995; Wilens et al., 1997a;Spencer et al., 1999a).

While these studies are reassuring in normoten- sive adults, long-term data are lacking, as are data in adults with borderline hypertension. It is recom- mended that clinicians inquire about familial hypertension, regularly follow patient’s blood pres- sure, and proceed with caution in patients with bor- derline hypertension. The addition of low-dose beta- blockers (i.e., propanolol at 10mg up to three times daily)orbusipirone(5-10 mguptothreetimesdaily) may be helpful in reducing the edginesdagitation associated with stimulant administration (Ratey, Greenberg, & Lindem, 1991).

Although not observed in short term studies of pemoline in ADHD adults (Wilens et al., 1996b), elevated liver function tests remain a concern when using this medication, and the FDA recommends liver enzyme tests every two weeks. While the bene- fit of biweekly liver function tests is debatable, discussion and close observation of hepatitis symp- toms, including change in urine/stool characteris- tic, abdominal pain, persistent flulike symptoms, or jaundice are useful in monitoring for hepatic dys- function with pemoline. Pemoline may have a role in the treatment of ADHD and comorbid sub- stance use disorders.

Medication Interactions

The interactions of the stimulants with other pre- scription and nonprescription medications are gen- erally mild and not a source of concern (Wilens & Spencer, 2000). Whereas coadministration of sym- pathomimetics (i.e., pseudoephedrine) may potenti- ate both medication effects, the antihistamines may

MonitoringTreatment with Stimulants

Once pharmacotherapy is initiated, monthly contact with the patient is suggested during the initial phase of treatment to carefully monitor re- sponse to the intervention and adverse effects. Given that many adults with ADHD have comor- bidites, once a successful regimen of medications is identified, the clinician must monitor for symptoms of comorbidity. For instance, some concerns have been raised about the anxiogenic properties of Adderall, and thus patients with comorbid anxiety disorder should be closely monitored (Horrigan & Barnhill, 2000). If issues of substance use are pre- sent, then consider the use of urine screens or hair sampling. Remember that methylphenidate will not be identified on the urine screen as amphet- amine since it is metabolized primarily to ritalinic acid (Wilens & Spencer, 1998).

Side Effects of Stimulants

The side effects of the stimulants in ADHD adults have been reported to be mild, with the following side effects most frequently reported: in- somnia, edginess, diminished appetite, weight loss, dysphoria, obsessiveness, tics, and headaches (Wilens & Spencer, 2000). No cases of stimulant- related psychosis at therapeutic doses have been reported in adults (Wilens & Spencer, 2000). Like- wise, despite the theoretical abuse potential of the stimulants, there have been no reports of stimulant abuse in controlled or retrospective studies of adults with A D H D (Langer, Sweeney, Bartenbach, Davis, & Menander, 1986). Although concerns about adverse cardiovascular effects of stimulants have been raised (Werry & Aman, 1975), effects appear benign, with minimal elevations of heart rate and blood pressure weakly correlated with

174

diminish the stimulant’s effectiveness. Excretion of amphetamines can be enhanced by acidification of the urine, and thus in somecasescliniciansmay need to limit the amount of citrusjuices patients drink at the time they take their medications. Extreme cau- tion should be exercised when using stimulants and antidepressants of the monoamine oxidase inhibitor (MAOI) type because of the potential for hyperten- sive reactions with this combination. The concomi- tantuseofstimulantsandTCAsiscommonpractice, with a recent study indicating no significant drug interactions [(Cohen et al., 1999).

New Stimulant Preparations

As already discussed, several new delivery systems for methylphenidate are available. Simi-

Jefferson B. Prince and Timothy E. Wilens

TABLE 9.2 Management of Common Stimulant-Induced Side Effects

Adverse effects Anorexia, nausea, weight loss

Insomnia, nightmares

Dizziness
Rebound symptoms

Irritability

Growth impairment

Management

Administer stimulant with meal
Use caloric-enhanced supplements (discourage forcing meals) Change preparations

Consider adjunctive treatment (nortriptyline, pergolide) Administer stimulants earlier in the day
Change to short-acting preparations
Discontinue afternoon or evening doses

Assess sleep hygiene
Consider adjunctive treatment (clonidine, mirtazapine, melatonin, antidepressants)

Reduce dose
Monitor blood pressure
Change to longer-acting preparation
Overlap stimulant dosing
Change to longer-acting preparation
Consider alternative or adjunctive treatment (small dose of short-acting stimulant; clonidine, antidepressant)

Assess timing of symptoms (during peak or offset phase) Reduce dose or change to long-acting preparation
Evaluate comorbid disorders (anxiety, mood, substance use) Consider alternative or adjunctive treatments (antimanic agents, antidepressants)

Attempt weekend or vacation holidays
If severe or persistent, consider alternative treatments

larly, clinicians can expect several other stimulant preparations to be available soon. These include S11381, a once daily formulation of Adderall. This compound utilizes the Micotrol delivery system employed in Carbatrol (a long-acting form of carbamazepine). Recent trials in children and adolescents have been published and are promising (McGough, Greenhill, & Biederman, 2000).

Despite the increasing use of stimulants for adults with ADHD, up to 50% do not respond, have untoward side effects, or manifest comor- bidity that stimulants may exacerbate or be in- effective in treating (Taylor et al., 1987; Shekim et al., 1990b; Biederman et al., 1993). Reports of nonstimulant treatments for ADHD adults have included the use of antidepressants, antihy- pertensives, and amino acids (Table 9.2).

9. Pharmacotherapyof Adult ADHD

175

et al., 1996a). In that study, response was noted during the initial titration at two weeks, which continued to improve at the six-week endpoint. Whereas a minority of subjects responded to <lo0 mg daily, the majority required more robust dosing (mean of 150mg daily) for efficacy.

Generally, TCA daily doses of 50-250mg are required, with a relatively rapid response to treat- ment (i.e., two weeks) when the appropriate dose is reached. Tricyclic antidepressants should be initi- ated at 25mg and slowly titrated upward within dosing and serum level parameters until an accept- able response or intolerable adverse effects are reported. Common side effects of the TCAs include dry mouth, constipation, blurred vision, weight gain, and sexual dysfunction. While cardiovascular effects of reduced cardiac conduction, elevated blood pressure, and heart rates are not infrequent, if monitored they rarely prevent treatment. Because serum TCA levels are variable, they are best used as guidelines for efficacy and to reduce CNS and car- diovascular toxicity.

Bupropion

Recently, the atypical, stimulant-like antidepres- sant bupropion (Wellbutrin@)has been reported to be moderately helpful in reducing A D H D symp- toms in children (Casat, Pleasants, & Fleet, 1987) and adults (Wender & Reimherr, 1990).In an open study of 19 adults treated with an average of 360mg of bupropion for 6-8 weeks, Wender and Reimherr (1990) reported a moderate-to-marked response in 74% of adults in the study (five dropouts), with sus- tained improvement at one year noted in 10subjects. Despite the small numbers of adults studied, bupro- pion may be helpful in ADHD, particularly when associated with comorbid mood instability or in adults with cardiac abnormalities (Gelenberg, Bas- suk, & Schoonover, 1991).Bupropion should also be started at very low doses (37.5mg) and titrated upward weekly to a maximal dose of 450mg per day. A D H D adults may benefit from the long-acting bupropion preparation. Bupropion appears to be

NONSTIMULANT MEDICATIONSIN THE TREATMENT OF ADULTS WITH ADHD

Here are some important points regarding nonsti- mulants in the treatment of adults with ADHD.

0 Tricyclic antidepressants and bupropion are second-line therapies.

0 Antidepressant dosing of the agents appears necessary for ADHD efficacy.

0 Serotonergic medications do not appear effective in the treatment of core ADHD symptoms but may be useful for comorbid anxiety and depression.

0 Cholinergic-enhancing medications may have a role in improving areas of inattention, but data are limited.

0 There is an empiric role for antihypertensives in aggression and tic disorders.

0 Empiric use of combinations may be appropriate in refractory and comborbid patients.

Antidepressants

Tricyclic Antidepressants

Within the past two decades, the tricyclic anti- depressants (TCAs) have been used as alternatives to the stimulants for ADHD in pediatrics (Spencer et al., 1996). Despite an extensive experience with children and adolescents (Spencer et al., 1996), there are only two studies of these agents in adult ADHD. Compared to the stimulants, TCAs have negligible abuse liability, once-daily dosing, and efficacy for comorbid anxiety and depression.

An initial chart review indicated that desipra- mine or nortriptyline, often in combination with other psychotropics including stimulants, resulted in moderate improvement that was sustained at one year (Wilens, Biederman, Mick, & Spencer,

1995b). A controlled trial of desipramine with a target dose of 200mg daily resulted in significant reductions in ADHD symptoms in adults (Wilens

176

more stimulating than other antidepressants, and it is associated with a higher rate of drug-induced seizuresthan other antidepressants (Gelenberg et al., 1991). These seizures appear to be dose related (>450mg/day) and elevated in patients with buli- mia or a previous seizure history. Bupropion has also been associated with excitement, agitation, increased motor activity, insomnia, and tremor.

Monoamine Oxidase Inhibitors (MAOIs)

The monoamine oxidase inhibitor antidepres- sants have also been studied for the treatment of ADHD. Whereas open studies with pargyline and deprenyl in adult ADHD showed moderate im- provements (Wender, Wood, Reimherr, & Ward, 1983;Wender, Wood, & Reimherr, 1985b), a more recent controlled trial of selegeline (Deprenyl) yielded less enthusiastic findings (Ernst et al., 1996). Ernst et al. reported dose-dependent impro- vements in ADHD symptoms on selegeline, which were not significant when compared to a high pla- cebo response. Although a pilot child-based study demonstrated efficacy of the reversible monoamine oxidase inhibitor moclobemide, data of its effective- ness for ADHD are not available in adults. The monoamine oxidase inhibitors may have a role in the management of treatment-refractory, nonim- pulsive adult A D H D subjects with comorbid de- pression and anxiety, who are able to comply with the stringent requirements of these agents. The con- cerns of diet- or medication-induced hypertensive crisis limit the usefulness and safety of these medi- cations, especially in a group of ADHD patients vulnerable to impulsivity. Additionally, other ad- verse effects associated with the monoamine oxidase inhibitors include agitation or lethargy, orthostatic hypotension, weight gain, sexual dysfunction, sleep disturbances, and edema, often leading to the dis- continuation of these agents (Gelenberg et al., 1991).

Serotonin-reuptake inhibitors (SRIs). The se- lective serotonin-reuptake inhibitors do not appear to be effective for ADHD (Spencer et al., 1996);

Jefferson B. Prince and Timothy E. Wilens

however, venlafaxine, an antidepressant with both serotonin and noradrenergic properties, may have anti-ADHD efficacy. In three open studies totaling 41 adults, 75% of adults who tolerated venlafaxine had a measurable reduction in their ADHD at doses of 75-150mg daily (Adler, Resnick, Kunz, & Devinsky, 1995; Findling, Schwartz, Flannery, & Manos, 1995; Reimherr, Hedges, Strong, & Wender, 1995). Although fur- ther controlled trials are necessary to determine its optimal dosing and efficacy, venlafaxine is gener- ally titrated from 25mg daily to more typical anti- depressant dosing of between 150 and 225mg daily for A D H D control. Side effects to venlafaxine in adults include nausea, gastrointestinal distress, anorgasmia, and concerns of elevated blood pres- sure at relatively higher dosing. Patients may experience discontinuation symptoms if the medi- cation is stopped rapidly. Venlafaxine is often used conjointly with stimulants for control of A D H D in adults.

Antihypertensives

The antihypertensives clonidine and guanfacine have been used in childhood ADHD, especially in cases with a marked hyperactive or aggressive com- ponent (Spencer et al., 1996). However, because of a lack of efficacy data and concerns of their seda- tive and hypotensive effects, their use in adults remains dubious. Beta-blockers may be helpful in adult A D H D but remain unstudied under con- trolled conditions (Mattes, 1986; Ratey et al., 1991). One small open study of propranolol for adults with ADHD and temper outbursts indicated improvement in both the ADHD symptoms and outbursts at daily doses of up to 640mglday (Mattes, 1986). Beta-blockers when added to stimulants have also been reported to be helpful for A D H D in three adults (Ratey et al., 1991), although it may be that this combination was help- ful by reducing the stimulant-induced adverse effects.

9. Pharmacotherapyof Adult ADHD

177

activity. The effect was more gradual than with methylphenidate and it was associated with some dizziness. Although compelling, the role of choli- nergic medications in treatment of ADHD remains to be further defined.

ModfaniI

Modfanil is a nonstimulant medication used in the treatment of narcolepsy. Its main effects appear to be on the hypothalamus rather than on central dopaminergic or noradrenergic pathways. Despite anecdotal reports of its usefulness in ADHD, initial trials demonstrated no benefit over placebo, and manufacture-sponsored trials were discontinued. It may have a role in cases of refractory ADHD.

Medications Under Investigation

Tomoxetine, an investigational antidepressant with selective noradrenergic-reuptake inhibitor properties, is under study for the treatment of ADHD in children, adolescents, and adults (Heili- genstein et al., 2000). In one controlled trial with adults, average daily doses of 76mg were well tol- erated and moderately effective in reducing core A D H D symptomology. Full therapeutic benefit may have been compromised by the short duration of the study (Spencer et al., 1998b). Although time to response with tomoxetine appears longer com- pared to the stimulants, it will likely provide an excellent alternative to the stimulants in patients with comorbid mood, anxiety, andlor substance use disorders. Reboxetine, a highly selective noradre- nergic-reuptake inhibitor, is expected to be avail- able in the United States soon. Although it has not been formally studied for the treatment of ADHD, clinicians may consider using it as an alternative for the treatment of ADHD with comorbid mood, anxiety, and substance use disorders. The investigational antidepressants

Amino Acids

Trials with the amino acids were in part under- taken with the assumptions that ADHD may be related to a deficiency in the catecholaminergic system and that administration of precursors of these systems would reverse these deficits. The results of open studies with L-DOPA and tyrosine and controlled studies of phenylalanine in adults with A D H D have generally been disappointing, despite robust dosing and adequate trial duration (Table 9.3) (Wood, Reimherr, & Wender 1982,

1985; Reimherr, Wender, Wood, & Ward, 1987). In these studies, transient improvement in ADHD was lost after two weeks of treatment.

Cholinergic Agents

More recently, the relationship of nicotine and ADHD has attracted attention, including findings of higher-than-expected overlap of cigarette smoking in A D H D children (Milberger, Bieder- man, Faraone, Chen, & Jones, 1997) and adults (Pomerleau, Downey, Stelson, & Pomerleau, 1995). One small study of two days’ duration showed a significant reduction in A D H D symptoms in adults wearing standard-size nicotine patches (Conners et al., 1996).Moreover, the authors have observed the efficacy of the nicotine patch in reducing A D H D symptoms in smokers who report the emergence of A D H D symptoms with cigarette cessation. Done- pezil, a cholinesterase inhibitor, increases the bioa- vailability of acetylcholine and has been found to improve memory and attention in Trisomy-21 and traumatic brain injury (Whelan, Walker, & Schultz, 2000; Kishnani, Spiridigliozzi, & Heller, 2001). Data on donepezil in ADHD are limited to case series in children and adolescents (Wilens et al., 2000). ABT-418 is a selective and potent nico- tinic cholinergic agonsit. In the one published study, symptoms of inattention improved preferen- tially over symptoms of impulsivity and hyper-

178

Jefferson B. Prince and Timothy E. Wilens

Study (year) N Woodet al. 8

(1982)
Wender et al. 22
(1983)
Wender et al. 11
(1985)
Woodet al. 19
(1985) crossover

Duration
Medication (weeks) Dose (mean)

L-DOPA 3 625mg

Mattes (1986) 13

Reimherr 12 et al. (1987) Shekim et al. 8 (1989)

Shekim et al. 8 (1990a)
Wender & 19 Reimherr

(1990)
Wilens et al. 37 (1995)

Open Retro- spective Open

Open

Open Open

Retrospective

Open
Open Double-blind

Tyrosine 8

Nomifensine 4 maleate

S-Adenosyl-L- 4 methionine Bupropion f%8

Desipramine 50 Nortriptyline

Venlafaxine 8 Venlafaxine Tomoxetine 7 Venlafaxine 8

Selegeline 6

Adler, et al. 12
(1995)
Reimherr 20
et al. (1995)
Spencer et al. 22
(1995) crossover

52% response
rate tolerated

Open

Ernst et al. 24
(1996) parallel

Improved anxiety scores

High placebo response, mild side effects

Comorbidity or levels not related to response
Side effects common, often loss of effect, inconsistent ADHD Dx

Findling et al. 9 (1996)

7/9 responded. reduction in ADHD
Mild improvement; 60-mg

dose better 68% response rate
Variable response

Wilens et al. 43 (1996a)
TOTAL 287

Double blind parallel
4 controlled 10 open 2 retro- spective

Desipramine 6

TABLE 9.3

Studies of Nonstimulant Pharmacotherapyin Adult ADHD

Design Open

(+ carbidopa) Pargyline 6

Deprenyl 6
Phenylalanine 2
Propanolol 3-50 528mg

Response N o benefit

13/22moderate improvement 6/9 responded, 2 dropouts

Poor
11/13 improved

Poor response, 4 dropouts
18/18 responded, reduction in ADHD Sxs

75% of patients responded Moderate response, 5 dropouts

68% response rate, response sustained
10/12 responded

8/12 responded

Comments

Side effects: nausea, sedation; low doses Delayed onset; brief behavioral action Amphetamine metabolite

Translent; mood improvement only
Part of “temper” study

14-day onset of action; tolerance developed Immediate response; one patient with allergicreaction

Mild adverse effects

10 subjects with improvementat 1year

Comorbidity unrelated to response, 60% on stimulants

4 subjects on other meds

Side effects led to 40% dropout rate Adrenergic agent, well

Open

30 mg

150 mg < 300mg

<2400 mg 360 mg

183mg 92mg

llOmg 109mg 76mg 150mg

20 & 60 mg

147mg Mixed 2-50 Moderate

Open

30 mg 587 mg

Double-blind

Duration of medication trial includes placebo phase. Abbreviations: Sxs = symptoms, Dx = diagnosis

9. Pharmacotherapyof Adult ADHD

179

of the medication for a reasonable duration of time. Patients with substantial psychiatric comor- bidity, who have residual symptomatology with treatment, or who report psychological distress re- lated to their ADHD (i.e., self-esteem issues, self- sabotaging patterns, interpersonal disturbances) should be directed to appropriate psychothera- peutic intervention with clinicians knowledgeable in ADHD treatment.

Stimulant medications are considered the first- line therapy for A D H D in adults (see Table 9.4). Given the high variability in effective dose, stimu- lants are typically started at low doses (e.g., Ritalin 5mg, Concerta 18mg, Metadate lOmg, Adderall 5mg, Dexedrine 5mg) in the morning and gradually titrated up. Tolerance of the medication as well as the time of effect should be noted by the patient. It is often clinically helpful for the adult to ask for obser- vations from significant others regarding the effects of the medication; however, if no one is available, data from the patients can be relied on (Murphy & Schachar,2000).Decisionsonhowmanydosesaday and how many days of the week to take the medica- tion should be tailored for each patient (Zametkin & Ernst, 1999). Consideration of another stimulant or class of agents is recommended if an ADHD adult is unresponsive or has intolerable side effects to the initial medication. The use of TCAs and bupropion can improve anti-ADHD response to the stimulants, whereas the SRI and other antidepressants can be used adjunctly for comorbid depression, anxiety, or obsessive-compulsive disorder. The effect of age, long-term adverse effects, and stimulant use in sub- stance abusing subgroups of A D H D remains un- studied. Monitoring of routine side effects, vital signs,and themisuse of the medication is warranted.

The antidepressants, namely, TCAs and bupro- pion, are less well studied, appearing useful for stimulant nonresponders or adults with concurrent psychiatric disorders, including depression, anx- iety, and active or recent substance abuse (Wender & Reimherr, 1990;Wilens et al., 1996a). Compara- tive data between the antidepressants and stimu- lants coupled with studies in children support that

S-adenosylmethionine and nomifensen have also been shown to be effective for ADHD in adults, although they remain unstudied under controlled conditions (Shekim, Masterson, Cantwell, Hanna, & McCracken, 1989; Shekim, Antun, Hanna, McCracken, & Hess, 1990a). GW320659 is a rela- tively short-acting noradrenergic/dopaminergic- reuptake inhibitor under study for ADHD in children and adolescents (Swanson et al., 2000; Deveaugh-Geiss, et al., 2000). Although it remains unstudied in adults with ADHD, Phase I1 trials demonstrated reductions of 20% in Conners Teachers Rating Scales and a half-life of 7 hours with linear pharmacokinetics.

CLINICAL STRATEGIES FOR THE PHARMACOTHERAPY OF ADHD IN ADULTS

Basic clinical strategies for the pharmacother- apy of adults with ADHD include the following.

Set clear, realistic treatment goals with the patient.
Stimulants are the first-line medications.
If the first stimulant is not effective or tolerated, consider an alternative stimulant. When comorbidites are present, prioritize treatment.

Use additional therapies to support and complement the effects of medication.
Use remedial servicesto support the patient in work and educational settings.

Once you have established the diagnosis of ADHD as the primary current problem, patients should be familiarized with the risks and benefits of pharmacotherapy, the availability of alternative treatments, the likelihood of adverse effects, as well as the prognosis both with and without medi- cations. Patient expectations need to be explored and realistic goals of treatment defined. Likewise, the clinician should educate the patient that each medication trial requires adherence to the dosing regimen as well as using clinically meaningful doses

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TABLE 9.4

Symptoms

Worsening or unchanged ADHD symptoms
Inattention, impulsivity, hyperactivity

Intolerable side effects

Symptoms of rebound

Development of tics or Tourettes Syndrome (TS), or use with comorbid tics or TS

Emergence of dysphoria, irritability, acceleration, agitation

Emergence of major depression, mood lability, or marked anxiety symptoms

Emergence of psychosis or mania

Adapted from Wilens & Spencer, 2000

Strategies in Difficult ADHD Cases

Interventions
Change medication dose (increase or decrease)

Change timing of dose
Change preparation, substitute stimulant
Evaluate for possible tolerance
Consider adjunctive treatment (antidepressant, alpha- adrenergic agent, cognitive enhancer)
Consider adjusting nonpharmacologic treatment (cogdive/ behavioral therapies or coaching or reevaluating neuropsychological profile for executive function capacities)

Evaluate if side effect is drug induced
Assess medication response vs. tolerability of side effect Aggressive management of side effect (change timing of dose; change preparation of stimulant; adjunctive or alternative treatment)

Change timing of dose
Supplement with small dose of short-acting stimulant or alpha- adrenergic agent 1 hour prior to symptom onset
Change preparation
Increase frequency of dosage

Assess persistence of tics or TS
If tics abate, rechallenge
If tics are clearly worsened with stimulant treatment, discontinue
Consider stimulant use with adjunctive anti-tic treatment (haldol, pimozide) or use of alternative treatment (antidepressants, alpha-adrenergic agents)

Assess for toxicity or rebound
Evaluate development or exacerbation of comorbidity (mood, anxiety, and substance use, including nicotine and caffeine) Reduce dose
Change stimulant preparation
Assess sleep and mood
Consider alternative treatment

Assess for toxicity or rebound
Evaluate development or exacerbation of comorbidity Reduce or discontinue stimulant
Consider use of antidepressant or antimanic agent Assess substance use
Consider nonpharmacologic interventions

Discontinue stimulant Assess comorbidity Assess substance use Treat psychosis or mania

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jointly with fluoxetine has been reported to be well tolerated and useful in improving depression in ADHD adolescents (Gammon & Brown, 1993) and appears useful in adults with the same comor- bidity. In cases of partial response or adverse effects with stimulants, the addition of low-dose SRIs, TCAs, or beta-blockers has been reported to be helpful (Ratey et al., 1991; Gammon & Brown, 1993). While the stimulants appear to be well tolerated with TCAs and SRIs (Cohen et al., 1999), clinicians should consider potential drug interactions as have been described between TCAs and some SRIs (Aranow et al., 1989).

Managing Suboptimal Responses

Despite the availability of various agents for adults with ADHD, there appears to be a number of individuals who either do not respond or are intolerant of the adverse effects of medications used to treat their ADHD. In managing difficult cases, several therapeutic strategies are available (Table 9.4). If adverse psychiatric effects develop concurrent with a poor medication response, alter- nate treatments should be pursued. Severe psychi- atric symptoms that emerge during the acute phase can be problematic, irrespective of the efficacy of the medications for ADHD. These symptoms may require reconsideration of the diagnosis of A D H D and careful reassessment of the presence of comor- bid disorders. For example, it is common to ob- serve depressive symptoms in an ADHD adult that are independent of the ADHD or treatment. If reduction of dose or change in preparation (i.e., regular vs. slow-release stimulants) does not resolve the problem, consideration should be given to alternative treatments. Neuroleptic medi- cations should be considered as part of the overall treatment plan in the face of comorbid bipolar disorder or extreme agitation. Concurrent nonpharmacologic interventions such as behav- ioral or cognitive therapy may assist with symptom reduction.

stimulants are generally more effective in reducing ADHD symptoms (Spencer et al., 1996). In add- ition, the response to the stimulants is rapid (Wood et al., 1976; Spencer et al., 1995), while antidepres- sants demonstrate improvement up to four weeks after titration (Wilens et al., 1996a). Although some adults may respond to relatively low doses of the TCAs (Ratey, Greenberg, Bemporad, & Lindem, 1992), the majority of adults appear to require solid antidepressant dosing of these agents (i.e., desipramine >150mg daily). Selegiline, a short-acting MAO-B inhibitor used primarily for Parkinson’s disease, has some potential benefit in adults with ADHD. Monoamine oxidase inhibitors are mildly effective and are generally reserved for treatment-refractory adults who can reliably follow the dietary requirements. The antihypertensives may be useful in adults with ADHD and aggressive outbursts (Mattes, 1986), tic disorders, impulse control disorders, or bipolar disorder or those with adverse effects to first- and second-line medi- cations. The amino acids have not been shown effective, and the cholinergic-enhancing com- pounds remain to be studied comprehensively in ADHD adults.

COMBINED PHARMACOTHERAPY

Although systematic data assessing the efficacy and safety profile of combining agents for ADHD in adults are lacking, empiric use of combination treatment may be necessary in those who have residual symptomatology with single agents or psy- chiatric comorbidity. For example, in a recent nat- uralistic report on TCAs for adults with ADHD, 84% of adults were receiving additional psycho- active medications, with 59% receiving adjunctive stimulants (Wilens et al., 1995b). These findings are similar to controlled data in juvenile ADHD, in which the combination of methylphenidate and desipramine improved the ADHD response more than either agent singly (Rapport, Carlson, Kelly, & Pataki, 1993). The use of methylphenidate con-

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Combining Psychotherapies with Medications

Although the efficacy of various psychothera- peutic interventions remains to be established, a retrospective assessment of adults with A D H D indi- cated that traditional insight-oriented psychothera- pies were not helpful for ADHD adults (Ratey et al., 1992). A cognitive therapy protocol adapted for adults with ADHD has been developed (McDer- mott, 1999)that preliminary data suggestiseffective when used with pharmacotherapy (Wilens, McDer- mott, Biederman, Abrantes, & Spencer, 1997b).

SUMMARY

The aggregate literature supports the notion that pharmacotherapy provides an effective treat- ment for adults with ADHD. Effective pharmaco- logical treatments for ADHD adults to date have included the use of the psychostimulants and anti- depressants, with unclear efficacy of cognitive en- hancers. Structured psychotherapy may be effective when used adjunctly with medications. Groups focused on coping skills, support, and interper- sonal psychotherapy may also be very useful for these adults. For adults considering advanced schooling, educational planning and alterations in the school environment may be necessary. Further controlled investigations assessing the efficacy of single and combination agents for adults with ADHD are necessary, with careful attention to diagnostics, symptom and neuropsychological out- come, long-term tolerability and efficacy, and use in specific ADHD subgroups.

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Spencer, T., Biedeman, J., Wilens, T. E., Faraone, S. V., & Li, T. (1994). Is attention deficit hyperactivity disorder in adults a valid diagnosis?Harvard Review ofPsychiatry, I , 326-335.

Spencer,T.,Wilens,T.E.,Biederman,J.,Faraone, S.V.,Ablon, S . , & Lapey, K . (1995). A double blind, crossover compari- son of methylphenidate and placebo in adults with child- hood-onset attention deficit hyperactivity disorder. Archives of GeneralPsychiatry, 52, 434443.

Spencer, T., Biederman, J., Wilens, T., Harding, M., O’Donnell, D., & Griffin, S. (1996). Pharmacotherapy of attention def- icit disorder across the life cycle. Journal of the American Academy of Child and Adolescent Psychiatry, 35(4), 409-432.

Spencer, T., Biederman, J., Wilens, T., Prince, J., Hatch, M., Jones, J., Harding, M., Faraone, S., & Seidman, L. (1998b). Effectiveness and tolerability of tomoxetine in adults with attention deficit hyperactivity disorder. American Journal of Psychiatry, 155(5), 693-695.

Spencer, T., Biederman, J., Wilens, T., Prince, J., Girard, K., Parekh, A,, Doyle, R., Kagan, J., & Bearman, S. K. (1999a). Efficacy and tolerability of adderall in adults with ADHD. Scientific Proceedings o f t h e American Academy of Child and Adolescent Psychiatry. (Eds.), Chicago: American Academy of Child &Adolescent Psychiatry.

Spencer, T., Wilens, T., Biederman, J., et al. (1999b). Effective- ness and tolerability of Adderall for ADHD in adults. Scien- tific proceedings of the American Psychiatric Association pp. 101-141. Washington, DC: The association.

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Wilens, T. E., Biederman, J., Wong, J., Spencer, T. J., & Prince, J. B. (2000). Adjunctive donepizil in attention deficit hyperactivity disorder in youth: Case series. Journal oj Child and Adolescent Psychopharmacology, 10, 217-222.

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I0 Career Impact:

Finding the Key to Issues Facing Adults with ADHD

Rob Crawford, M.Ed., Veronica Crawford, M.A.

INTRODUCTION

Perhaps it is best said up front that everyone struggles with trying to make the correct decision on what kind of career is “right” for them. How- ever, there is a difference between those who struggle and eventually find their way into the light and those who struggle and seem to stumble endlessly through the night. There is a quote that identifies quite well the reason so many individuals with hidden disabilities seem to struggle more than necessary: “We never know how high we are till we are called to rise and then, if we are true to plan, our statures touch the skies” (Dickenson, 1870).

If one thinks about this statement in relation- ship to individuals who have hidden disabilities such as attention deficit hyperactive disorder (ADHD), it becomes clear where the complications begin. If one has not had opportunities to “be called” or if past experiences have not been posi- tive, self-esteemmay be low. When low self-esteem is combined with a lack of a clear picture of what can realistically be achieved, individuals with ADHD may not easily recognize opportunities when they arise.

Clinician’sGuideto Adult ADHD:
AssessmentandIntervention
ISBN0-12-287049-2 187

To be able to be called on, each of us has to know what we can do, to understand what consti- tutes our strengths and weaknesses, and to relate these to the real world. Over the years, our work with adolescents and adults with ADHD and re- lated disabilities has allowed us to see patterns of difficulties,many of which are avoidable and pre- dictable. In this chapter, we outline some strategies that will assist the clinician to: (1) understand aspects of the therapeutic process involved in job development and career planning for individuals with ADHD; and (2) assume the role of advisor, mentor, and guide for individuals who are seeking to find their place in the world of work.

BARRIERSTO REALISTICCAREER DECISION MAKING

Developing meaningful clinical and practical in- sight into what happens to adults with hidden dis- abilities is something that must be considered as a work in progress. Much of what will be discussed is taken from research and practice. Although these issues have not been adequately explored in adults

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withADHDonindividualswithlearningdisabilities (LD), much of the literature referring to LD in the workplace is relevant to adults with A D H D con- cerns (Nadeau, 1995).Individuals with LD, ADHD, and related hidden disabilities express similar con- cerns, frustrations, and workplace difficulties.

In essence, the very issues associated with career planning and job development for adults with ADHDarethesamecoreissuesforadultswithLD (Nadeau, 1995). Some of these areas adversely impacting employment success are most often due to the lack of understanding supervisors or cowor- kersexpectations,choosinganinappropriatecareer, andlackingthesenseofself-competencetodealwith these predicaments that challenge adults with ADHD in the workplace.

Self-esteem is a critical part of one’s ability to make informed and realistic life choices. Recent literature studying successful adjustment in adults with L D with other, comorbid conditions showed that healthy self-esteem is based on self-confidence derived from personal mastery, the experience of having been able to undertake and accomplish per- sonally chosen tasks (Wren & Einhorn, 2000). In- dividuals with hidden disabilities frequently have difficulty developing healthy self-esteem because of the daily frustrations they often face.

Many struggle with self-blame and are over- come with guilt. Oftentimes, they misunderstand the basis of their difficulties,which results in imma- ture, passive-aggressive,or self-defeatingpatterns of problem-solving strategies (Nadeau, 1995).Difficul- ties additional to the disability may contribute to adjustment problems in the workplace-specifically low self-esteem. Further, Wren and Einhorn (2000) suggest that “pathological” self-esteem is self- esteem as an end in itself. They contend that patho- logical self-esteem occurs when people try to make children feel good about apart from their accom- plishments or behaviors. This pattern, starting in early life, can ultimately interfere with healthy self- esteem development in adults with disabilities.

Although familymembers, teachers, and counsel- ors may be well intended and supportive, there is a

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careful balance asto what information isprovided to developing children so that they can develop an accurate sense of who they are as human beings. In other words, even though people have disabilities, it is unnecessary to “protect them from reality,” be- cause the outcome when they enter adulthood will be far too demoralizing. Professionals often see this sort of outcome, where adults suffer because they havenotdevelopedanaccuratesenseofwhotheyare as human beings. The therapeutic process needs to startheresothatthecareer-decision-makingprocess is realistic and has a chance for success.

The following discussion focuses on a variety of problems the therapist might see in clients seeking career counseling. Although clients with ADHD may present with these difficulties,adults with vari- ous other disorders may have similar issues.

No Awareness of Weaknesses

This means a lack awareness and possibly not understanding that “healthy human balance” entails the notion that everyone has a weakness. The next step in therapy is to understand how these weaknesses impact occupational or career adjust- ment, to develop coping strategies, and to work on improving or bypassing relevant weaknesses that can’t be changed. Without this type of selective process, clients may pursue unrealistic career goals or focus exclusively on jobs they consider respect- able, that pay well, or that are “fun.”

Unwillingnessto Seeweaknesses

An unwillingness to see weaknesses may be an attempt to protect from the devastating notion that “I’mnot good at anything.” Denial ofweakness may set in and may lead to unrealistic career goals. Or worse, the individuals may be choosing a career because they are fearful someone will identify their weaknesses. These clients may choose careers that are less challenging than they can handle.

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Perseveration

Some clients may perseverate, get fixated, or appear to make connections with everything. Career decision making in these situations becomes complicated, and anxiety can be high. In this in- stance, it may be too cumbersome for clients to look at their strengths, weaknesses, interests, and values. These individuals may be unable to stay on task, complete assignments, or persevere with deci- sions they make regarding careers.

Dependency

Clients may become overly dependent on family members when they have been overprotected or have not had many autonomy experiences. Career decisions may be difficult for these individuals, and family members may stay overinvolved. Fear of making the wrong decisions may persist. The ther- apist may address these fears and help the client make more autonomous decisions.

Egocentricity

Some clients may appear egocentric. Feelings of inadequacy may be at the root. Clients may need lots of reassurance to develop a more positive self- image. Becoming more aware of this balance between strengths and weaknesses, without des- troying safety nets, may decrease egocentric think- ing. Other strategies for reconciling egocentric behaviors are presented later in the chapter.

Insecurity

Clients who feel insecure and lack confidence in their decision-making abilities will need support from the therapist. Informedcareer decision-making can be nurtured with a compassionate, involved therapist. More directive techniques may be helpful

here, and clients who feel insecure may be quite successfulwhen matched with ajob developer. Para- professionals may be used to assist the client in gathering information about career options and when “trying on” new roles or job identities.

lack of Awareness

Theseclientshavenotbeenexposedto“choices.” Most of them don’t even realize they have other choices. These clients do very well when they are shown they have skills that transfer to the job and are provided examples of how those skills can be cross-utilized in other careers.

Perfectionism

Working with a perfectionist can be very trying. Adults with ADHD who have perfectionist tenden- cies are generally never satisfied with how things are being handled, either by the therapist or them- selves. They often overlook their accomplishments or strengths, and focus on weaknesses, inconsist- encies, or failures. In many instances, they need permission to be human-to be less than perfect. Perfectionistic individuals may need high levels of structure and may respond best when methods for selecting a career are made explicit. Written-down career options, career goals, and ways to measure satisfaction or success are generally helpful. Writ- ten plans may help perfectionistic clients with ADHD visualize their options and feel more in control of the process, and may assist them in moni- toring their progress in meeting career goals. The written plan may need to include strategies for attending to successes as well as setbacks.

STARTING OUT WITH A REALISTIC PICTURE

By addressing these general behaviors and per- sonality traits, the therapist sets the stage for career counseling. In many instances, adults with ADHD

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and/or LD don’t fully understand their own unique processing strengths and deficits. This lack of awareness may lead to over- or underestimating one’s talents and one’s ability to perform satisfac- torily in a particular job (Wren & Einhorn, 2000). Clinicians can help their clients by investigating these issues in a supportive therapeutic environ- ment prior to the onset of community-based career exploration. By helping the adult with A D H D become more aware of how the disorder affects the world of work represents an important initial step. A careful review of background history will assist in developing a realistic picture.

Hidden disabilities like A D H D may pose ex- treme career challenges on a daily basis. Gerber and Reiff (1994) found that many adults with LD did not benefit from counseling and vocational guidance because of unrealistic goals that were set too high. The authors hypothesize that a lack of trial-and-error experiences in childhood places in- dividuals with disabilities at risk. Two types of experiences appear salient: (1) overprotection in childhood; (2) repeated failures that were demoral- izing. In the latter instance, individuals did not experience failure as a temporary condition, as a necessary part of the learning curve.

We are not suggesting that the therapist should further demoralize the client by “bursting the bubble.” We are suggesting that to be successful, career counseling must include a realistic picture of what a job entails, what abilities are needed, and the overall job requirements, such as occupational training and skills (Gerber & Reiff, 1994). With a realistic picture in place, the adult with A D H D can begin to see whether the career is a good personal fit or a mismatch.

The following is an example of unrealistic deci- sion making in a young man named Joe. Joe wants to go to college, and the reason is that the rest of his family went to college. His family members are doctors, lawyers, college professors, and business professionals. Joe didn’t want to go to just any col- lege, but only to the right university. In order to measure up to his family, Harvard and Yale univer-

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sities were on his short list. If he had to go a state college, then the University of California at Berkeley was his only pick. After all, he reflected, he had to be realistic, and he might not be able to get into other schools. Joe had been encouraged throughout his lifetime and was constantly told he could do any- thing he wanted if he would just put his mind to it.

Despite having borderline intellectual function- ing and ADHD (inattentive type), Joe was not aware of how his strengths and weaknesses matched his college goals. He did not have a good sense of what was required from highly competitive universities, and he did not have a backup plan if he was unsuccessful.

In this instance, a therapist could assist Joe by exploring his functional assets and matching these to his goals. The following questions could be used to help him make a more informed decision: What is required to be admitted to Harvard or Yale? Do my grades and test scores meet the minimum re- quirements? What course of study would I pursue? What careers are related to my program of study? What prerequisite academic skills do I need? Is this what I really want to do, or do I feel pressure to live up to someone else’s expectations? This process does not preclude Joe from pursuing a college edu- cation, but it does help him get a better match because he now has a more realistic picture of himself. In this situation, he might select an alter- native education setting that might give him a sense of ownership and pride of accomplishment.

Some clients decide that because their mother or father is in a particular profession, they should follow the same path. Little or no consideration may be given to environmental factors, the occupa- tional demands of the job, interpersonal skills that are needed, technology requirements, and work- place factors that constitute career viability. Let’s assume for a moment that a client named Jane comes to you for appropriate career counseling. Jane has a diagnosis of A D H D (primarily hyper- active type). Jane is gifted mathematically and demonstrates an amazing capacity to understand computer software applications without needing to

10. Career Impact: Finding the Key to Issues Facing Adults with ADHD 191

read a manual. She seems to be a perfect candidate for college. Jane gets her degree in accounting, believing that one day she will take over the family accounting firm. Jane shares with the clinician that she finds it hard to sit in one place for any length of time, and hates to go over documents that take any longer than 10 minutes to review.

A background check of Jane’s college record reveals that she was successful when using allowed reasonable accommodations and medication for in- attention. Jane spent so much extra time trying to finish her college education that there was no time left over to work part time. Besides, why should she need to work? She would soon be a partner in the family business, as everyone had planned her whole life. Jane comes to see you, anticipating great things will happen immediately, but she quickly realizes the unanticipated obstacles to her goals. The kind of career she has selected forces her to do just what is most difficult for her to achieve: sustain concentra- tion, sit for extended periods of time, and review numerous lengthy legal documents. Jane and her family are taken completely by surprise They had not anticipated this mismatch and were at a loss to explain why she was having difficulties and perform- ance failures.

Clients with job problems are often poorly matched for their jobs. They rarely fail because of incompetence or poor ability. In fact, most have great strengths and high potential if they find the right job that maximizes their personal assets (Nadeau, 1995). It is essential when young people begin to explore career options, especially those with ADHD and other hidden disabilities, that they be carefully guided along the way. Making informed decisions that are based on their capabil- ities, interests, and values and their sustainability to do what is required both in preparing for and working in the chosen field is crucial to success.

There are ample reasons someone with A D H D may make unrealistic career decisions beyond jumping into something because someone else is doing it. Most of the clients we have served either want to go into careers that are well below their

capabilities, or they seek careers that are highly unachievable. Here are some of the comments that clients with both LD and ADHD repeatedly state in sessions:

I can do anything I want-I just don’t want to. My parents have money, so I really don’t need

to worry.
I’m still young-I don’t really need to make up

my mind until I am 30.
Lots of people change careers many times-if I

don’t like this one, I’ll just switch.
So what if I had trouble in high school? Things

are different now-I just didn’t try. A D H D goes away when people become adults-this won’t impact my career.

I believe the right job is out there. No need to worry-it will find me eventually.

I should just follow my dreams-do what I love and the rest will fall into place.

The most creative people in the world have ADHD. Look out world, here I come!

There are thousands of jobs out there-I’ll just get the one that pays top dollar.

I’m going to go to college-get a degree and then go to work and do something neat.

My parents do great, and they didn’t get any education or training.

I saw a job sign on a telephone poll: “Work from home, earn up to $5000 per week.” I am going to be in demand in a few years because of all my diverse experience.

I want to have lots of different jobs so I can decide which is best for me.

So what if I have been fired from ten jobs this year? It was their fault, not mine.

Look, I have ADHD-mployers need to understand I don’t do well in the morning.

I can’t do any other type of work-it’s too hard to learn new skills.

Go to school? No way! My experience with school in the past has been horrible.

No one can tell me what to do-they aren’t me. how do they know what I need?

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Though some of these examples appear humor- ous, what frequently lays behind these statements are themes of inadequacy, fear, frustration, confu- sion, and sadness. Realistically speaking, most of these clients have a great desire to be successful at something they will enjoy. Unfortunately, they mask or hide these desires because they have been repeatedly hurt by real or imagined failure, or have not had enough practical experience in life to know what it takes to succeed in the long run.

REFRAMING AND INVOLVEMENT

There are some steps that can make the differ- ence in what is done to prepare adolescents and adults for making well-thought-out career deci- sions. Strategic planning and directed action can begin in the school and home environments. One effective method contributing to successful plan- ning is to work on reframing the minds of these young people. Vogel and Reder (1998) contends that career goodness-of-fit (i.e., choosing employ- ment that maximizes strengths and minimizes weak- nesses) correlates directly with self-understanding and awareness.

Reframing is the initial critical step to helping young people understand themselves. Doing so helps them to become clearer about what they want out of life and how to get there. The process of reframing is especially applicable to those with disabilities. Gerber and Reiff (1994) suggest that it is necessary to:

Recognize the disability. Its impossible to overcome a disability unless it is recognized. Accept the condition-both negative and positive ramifications of the disability. Understand the situation-the disability and all its implications.

Act. All recognition, acceptance, and understanding in the world is irrelevant without consciously deciding to take specific action toward goals.

Rob Crawford and Veronica Crawford

Professionals must begin to pull the pieces of the disability puzzle together for these young people. First, stress efforts to understand oneself as a total person (including that part of oneself that has a disability). The intent is to make sure that individ- uals do not view or define themselves only from a disability or disorder perspective. Simply providing a diagnosis is not enough and will actually harm clients if they do not understand the implications of those symptoms and are not provided with strat- egies on how to self-manage or, in extreme cases, how and when to ask for reasonable accommoda- tions. Inaccurate and unhealthy notions about future prospects should be reframed in a more posi- tive and hopeful light so that patients can begin to rebuild their self-esteem and believe successful treatment is possible (Nadeau, 1995).

Reframing can also help in the process of career decision making. In order to realize its full value as a practiced tool, reframing preparation should begin during the formal educational years, com- mencing no later than age 14. Too often clinicians see clients who are unprepared or who lack know- ledge about how to identify or discuss their desires, needs, and goals as adults. They have not been given opportunities or practice in becoming self- determined (advocating for themselves). For a suc- cessful transition into adulthood, communication and life planning responsibilities should be done at the beginning of high school to better prepare for the variety of adult issues they will face.

Typical adult communication requirements, such as problem ownership, is a basic requirement for competent decision making. Effective problem- solving skills give students a positive presence or enable them to learn how to cope, to effectively advocate for themselves, and to negotiate in a non- confrontational manner when they do eventually go to work. Rehearsing and practicing social skills usually increases the likelihood that students will experience social acceptance on the job.

Students who can participate in team building enhance their ability to gather support for a career from other people and resources in a school-based

10. Career Impact: Finding the Key to Issues Facing Adults with ADHD 193

ecosystem (peers, family, community, teachers, etc.) and transfer them into an adult ecosystem (peers, family, coworkers, employers, community, rehab professionals, etc.). Implementing ecosyste- matic interventions early and routinely diminishes the need for ongoing support, with the services of external trainers and advocates eventually fading out (Rusch & Chadsey, 1998). In summary, these prerequisite skills must be developed for clients to have a more self-assured and realistic view of their future. Without this type of involvement in school and family settings, they find themselves unpre- pared for making informed and independent deci- sions about their futures. The desire to succeed fuels the engine, and goal orientation sets the direc- tion. But a practiced ability to reframe experience ultimately empowers individuals to utilize behav- iors that will determine successfulemployment out- comes (Vogel and Reder, 1998). Those who have had these experiences are more aware and informed and have fewer difficulties in achieving their goals.

CLIENT INVOLVEMENTAND DEVELOPING SELF-DETERMINATION

The concepts of self-determination and becom- ing self-determined are not new. It is a critical component of treatment plans in the disability field. Structured opportunities, plans, lessons, or experiences with self-determination are essential. Older adolescents or adults who demonstrate self- determination skills usually have had experiences in advocating for themselves, such as participating in individualized education plan (IEP) meetings, discussions with teachers and counselors, and se- curing their own employment or volunteer experi- ences in high school.

In reviewing the literature regarding techniques leading to enhanced self-determination, it is clear that educators and individuals with disabilities must become partners, both having important roles to play (Field, Hoffman, St. Peter, & Sawi- lowsky, 1992). Self-determined individuals are not

as likely to be overprotected by their families. Insu- lating and shielding children all too frequently leads to fostering dependency later in life. Young adults don’t need to learn to determine their own future, because everyone else (e.g., family) is in charge of his or her life decisions.

Instead, if children are to become self-deter- mined adults, the family must allow the children to make mistakes so they can learn from them, allow them to be involved in decisions about themselves. The family can act as a guide to children, gradually giving them a bigger part in advocating for themselves as they mature. Self- awareness offers a sure rudder for keeping career decisions in harmony with an individual’s deepest values (Goleman, 1998).

Over the years, an adult with ADHD can begin to understand and accept himself because of these experiences. In short, what is done for a child with hidden disabilities should be the same as for any other child-every person is going to experience difficulties, it is the natural order of life. Everyone involved with this individual should be helping her to become independent, and although additional difficulties mitigated by the condition will arise, making the individual with ADHD an active part of solving those problems is the key to success.

Many adults exiting therapy or career counsel- ing lack the basic skills of self-determination when starting treatment. There are many ways in which a person can become self-determined. If the client is to learn how to apply these skills to the adult world, specifically in making an informed career decision, several things need to occur. One particu- larly useful model for setting up a system of self- determination skills for adults with A D H D is posited by Campeau and Wolman (1993), Field, Hoffman, St. Peter, and Sawilowsky (1992), Hal- pern (1993), and Mithaug (1991). These can be combined with earlier action steps on reframing, and include six major steps:

1. The individual identifies and expresses his or her own needs and interests.

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2. The individual sets expectations and goals to meet his or her needs and interests.

3. The individual makes choices and plans to meet goals and expectations.

4. The individual takes action to complete plans.

5. The individual evaluates results of actions. 6. The individual adjusts plans and actions until

the goal is achieved.

These six steps can be integrated into educa- tional, family, community, and rehabilitation areas. Developing program and therapeutic consistency is critical for the individual, who will need to receive similar messages from all areas. Developing expect- ations and timeliness, with client input, allows the individual to feel empowered and in charge of set- ting the therapeutidife direction.

According to Gerber and Reiff (1994), the extent to which adults with LD shape their own lives, within their interests and capacities, seems to figure prominently in their overall resilience. This resili- ence develops only when adults feel they can help themselves or know who to go to when they need help. Without these skills, the individuals may give excuses, try to lie to protect themselves, and appear to be “unmotivated.”

If the primary treatment objective is to help create personal consistency and promote increased involvement from clients, professionals must pro- vide them project-specific information as reference points to work from. It is best if there are specific tasks associated with each stage of information processing. An example of this type of staging is to provide objective sources of information regard- ing what skills are sought by employers. Exploring the natural application of these skills and how to build them into education, training, work, family, and rehabilitation models will reinforce the compe- tency messages.

An excellent starting point is to use the resources developed by the U.S. Department of Labor’s (1992) Secretary’s Commission on Achieving Neces- sary Skills (SCANS); “Learning a Living, A Blue-

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print for High Performance.” These materials list the competencies and skills needed by all workers and define the know-how and application of the concepts to workplace issues that are likely to arise.

The professional, mentor, therapist, or coun- selor plays an important role in the process of helping the client to become more self-determined. The therapist and client could work together to: investigate and understand the client’s background (e.g., school records, work experience); identify the presenting problems (e.g., unproductive behaviors and attitudes); specify and understand the em- ployer-identified career skills needed for the job; and investigate the SCANS blueprint.

THE ROLE OF THE PROFESSIONAL AS MENTOR AND FACILITATOR

Career counselors work to help a person select a career choice based on multiple vocational, per- sonality, and academic evaluations. For average persons, an array of assessment data can be very useful, because they can independently take the information, explore it, and make a decision on their own if they wish to pursue it.

The most effective methods for adults with ADHD are those that integrate a number of profes- sionals who can help the clients make an informed decision. The usual role of a career counselor in- volves an evaluation of: (1) interests, (2) strengths and skills, (3) temperament and personality type, and (4) values and needs. This information helps to guide the individual to a better sense of “career self’ (Nadeau, 1995). When the career counselor focuses on these areas alone, issues surrounding the disabil- ity and the functional impact it might have on work performance are often ignored.

Therapists need to be familiar with the com- munity resources that are available for remedial compensatory education, because the cognitive or- ganizers used in therapy may not be sufficient (Ger- ber & Reiff, 1994). For example, a counselor is working with a 25-year-old male who has recently

10. Career Impact: Finding the Key to Issues Facing Adults with ADHD

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What are specifics that feel as natural and automatic as writing with my dominant hand?
What are my priority values that must be considered to feel good about myself? What are my aptitude levels that maximize success?

What is my energy pattern throughout the day, week, month?
What are my dreams, and how do they relate to the real world of work?

What are my pieces of jobs that always attracted me, and how can those pieces be threatened together?
How realistic are my related options in terms of today’s job market needs?

How much do I really know about the related options?
How can the options be tested out, rather than tried out, with the possibility of failure? What special challenges do I have?

How do my challenges impact me?
How might my challenges impact the work options?
How could the challenges be overcome by appropriate strategies and interventions? How great is the degree of match between the option and the real me?
Can I test out the degree of match before pursing the field?
How could I enter and sustain the chosen work environment?
What supports can be put in place to ensure long-term success?

been diagnosed with A D H D (inattentive type). The counselor asks questions to determine the type of career he is considering. It is likely that the client with ADHD may not have a good sense about career options, so career education may be a help- ful first step. A knowledgeable professional will know about local services and adult agencies avail- able for career awareness options. Further, a refer- ral can be made to the Department of Vocational Rehabilitation (DVR). There the young man can speak with a counselor and determine if he might qualify to get service support in college.

The DVR counselor will even help him (if accepted) to make an informed career decision through local vendors, private professionals, or other adult agencies specializing in career decision making and having a background in working with individuals who have disabilities. Some of these individualized services would include: providing vocational preparation (such as internships), on- the-job training, and other networking opportun- ities with area employers. Without appropriate support and referral to other agencies (e.g., One- Stop Centers, Mental Health), the young man with A D H D might pursue unrealistic career options and embark on a career path that leads to more frustration.

A therapist plays a critical and central role not only in giving pointers on where to go for help and how to get it, but also in helping the client become more self-aware of career realities. To cope more effectively, the client must be motivated to become more realistic about priorities and alternatives. There are some basic questions that lead to client- centered career decisions.

In her book Finding a Career That Worksfor You, Fellman (2000) poses these questions:

1. What are my passions. ..those interests that really “light me up”?

2. What have been my accomplishments thus far?

3. What personality factors contribute to my ease of handling life?

5. 6. 7. 8. 9.

10. 11. 12.

13. 14. 15.

16. 17. 18. 19. 20.

This list is not meant to form the entire therapy process, but it does help the client and the therapist to identify important information that will be needed for making informed career decisions. The questions also provide a framework for exploring careeroptions,forsolvingproblems,andforhelping the client to become more self-determined. Once this process begins, the client will have a greater oppor- tunity for success, self-confidence, and self-esteem

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(Nadeau, 1995). By seeking answers to these ques- tions, the client will be less bored and will have more personal satisfaction in pursuing a career goal that is in line with his or her truer interests, personality, and functional assetsAimitations.

Therapists can develop a partnership with their clients around issues related to career decision making. This partnership should focus on helping the clients become more self-determined and to exert more control over their life. Many adults with ADHD are tired of being misunderstood and have a history of having to explain themselves to others. They are tired of excuses, but they may be dis- couraged when they encounter setbacks, due to a lifetime of being misunderstood. When disappoint- ments do occur, adults with ADHD may not see these as a normal part of life. They have trouble learning from these experiences, and are not sure how to avoid similar disappointments or setbacks in the future. Self-improvement may seem unreach- able in these circumstances.

Practice in self-determination and reframing allows the client to walk away from a session with strategies for dealing with painful life experiences. These strategies can be used to show how painful experiences are a part of life and how to make better choices in the future.

PRACTICALTOOLS AND STRATEGIES FOR CAREER DECISION MAKING

The Career Decision-Making Process

Decision making is a common problem facing many individuals, and most people don’t know how to make decisions well. For the adult with A D H D , additional layers of difficulty surface in choosing between so many apparently conflicting options. You may face opposition because many adults with A D H D have trouble breaking down the key elements of decision making. The opposition is

Rob Crawford and Veronica Crawford

understandable because of the combination of high stakes involved with selecting an appropriate career and the potential consequences that a poor choice will result in frustration and self-defeating feelings.

Thus, the therapeutic process should address the anxiety, confusion, doubt, errors, embarrassments, and loss of past mistakes in a direct manner. Clients may alternate between self-doubt and overconfi- dence and exhibit stalling tactics, impulsive behav- iors, and despair resembling burnout.

They are likely to become overwhelmed by the sheer volume of data, overlooking relevant informa- tion or important details that lead to flawed choices. They may focus on the wrong information or be unable to organize information into meaningful concepts. These feelings may present as “learned helplessness’’and it may appear that the clients want a magical resolution to the career decision dilemma. Hammond, Keeney, and Raiffa (1999) believe that the ability to make smart choices is a fundamental life skill. They contend that it is one of the most critical determinants of how capable a person be- comes in handling life responsibilities and in achiev- ing personal or professional goals.

The next section of the chapter covers how to use critical-path decision making, combining task- oriented vocational counseling and career explora- tion activities. Successfulcareer-planning outcomes depend on more than luck for success. Successful results are enhanced by deliberate reasoning, plann- ing, and execution within the therapeutic relation- ship.

Can’t Make Up Your Mind? What’s the Problem?

Frank is a software specialist and has been working for a variety of dot-com companies for the past nine years. By nature, these jobs have a cycle of instability, where the products or services are rapidly developed, aggressively marketed, and sold to investors in 12-18 months. The company he works for now has kept him continuously employed

10. Career Impact: Finding the Key to Issues Facing Adults with ADHD 197

for almost three years. He has heard through the grapevine that the company may be acquired by a multinational corporation. While the pace of change was exciting and kept his interest in his younger years, Frank is now in his early 30s. He has two young boys in school and feels pigeonholed in his industry in a position he no longer likes. His previous work experience and family responsibil- ities contribute to the trapped feeling. He doesn’t know how to change his life, and he is afraid his decisions will adversely affect his family.

What is the real career decision to be made? Is it “Which software design company should I work for?” Or is it “Should I work for someone as op- posed to being self-employed?” How the decision- question is originally posed is vital to the outcome; it must be phrased carefully. The client and therap- ist work together to phrase the questions right. The way a problem is stated places boundaries around the choice to be made. Parameters can be identi- fied, alternatives can be considered, and evaluations can be conducted within this basic framework. Adults with ADHD tend to jump to an immediate decision, selecting the first thing that comes to mind. Or they may choose the most obvious alter- native without thinking about all the consequences. The therapist is there to help facilitate this process and to help the client take a fresh look as well as more carefully ponder career options.

By pointing out that this myriad of options isn’t necessarily a bad situation, the therapist can begin to reframe the issues. The decision-problem can be viewed as a time to be creative, a time to be adven- turous, and a time to pursue a more satisfying career that leads to greater personal achievement. Deci- sion-problems, whether related to career or to other dilemmas, are often fueled by specific “trig- gers.” Decision triggers are driving forces at work or in life that result in dramatic changes in personal status. For example, a young man graduating from high school is contemplating enrollment in collegeus a trade school. A mother of two worries that she will lose her job after an impending layoff. A talented computer specialist without a degree becomes a

father. It is good to approach these highly emotion- ally charged situations by investigating “trigger” events. Because of a history of failure or self-doubt, many adults with ADHD have a built-in tendency to persist in self-limitingprejudices. The client may feel, “I’m not very smart, or I’d know what to do,” or “I can’tgetanewjobrightnow.”The triggeristhemost direct link to the essence of any decision-problem, career related or other. In the case of themother who initially sees the problem trigger as losing herjob due to company cutbacks might be thinking the decision problem should be phrased as “Who will hire me now?” The real problem may actually be better phrased as “What’s the best way to use this situation to move up in the company?” She may not have to start sending r6surni.s out by the basketful at all. Another alternative may be to develop an internal networking plan to solidify her value to the newly merged company workforce.

By reframing the triggering event leads to the career decision-problem, the professional should help the client state the problem as clearly as pos- sible:

1. What assumptions does the client have about the career decision-problem? (E.g., I need a better job.)

2. What are the sources of the “triggering events”? (E.g., I read the newspaper.)

3. What are the connections between the “trigger” and the career decision-problem? (E.g., I need to increase my skills because of changes in technology.)

Most triggers come from others (work super- visor, parents) or from circumstances beyond the client’s control (labor trends and market forces). Although these life changes come to the client from external sources and may seem to offer few alterna- tives,thereisnothingtosaythattheclienthastowait for the worst to happen. Your clients do not have to settle for whatever they can salvage from the situ- ation. The threat of changing employment may ac- tually be an excellent way for clients to create a new set of circumstances more to their liking.

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Figure 10.1shows the relationship between career decision making and (1) assumptions, (2) “triggers,” and(3)connectionsandqualityoflife.Clarifyingthe decision-problem frequently takes a great deal of time. The therapist and client work together to gen- erate an accurate statement of the problem and brainstorm various alternative problem statements. In our earlier example, Frank should consider how being self-employed could affect his quality of life and family relationships. The therapist should work with Frank to help him determine that he was as open and honest about perceived constraints. These constraints may alter the way the decision-problem isframed. IfFrankchangesjobsbefore themerger, is he missing exciting opportunities by bailing out too soon? Help Frank to create a larger canvas, to expand his vision. This allows for a broader range of potential solutions.

GAINING CONTROL OF THE DECISION

Once the decision-problem has been identified, therapy can focus on consideration of the end

Rob Crawford and Veronica Crawford

opportunities

I have talents not being used

Passed over for Family financial

FIGURE 10.1 Career-planning decision.

Favorable local

technology changes

Decision Problem

I need to change my career direction. Which way to go?

result. What are the objectives? In this model, the importance of determining objectives allows for evaluation of options and other alternatives associ- ated with them. The personal nature of deciding on objectives become clear when the client reflects on questions like “What do I honestly want and need from this decision?” This is an appropriate time to begin using available careerAife values checklists and task analysis procedures to inventory specific vocational skills. Explore and examine work tasks at the job and at home for latent skills or interests. Evaluate what skills or life-enriching values are part of personal hobbies. This evaluation would include informal work done for home improve- ment or auto repair and spare-time activities such as Web designing for church and volunteering as math teacher for an adult education program.

Work-related behaviors should be explored. These include: punctuality, attendance, attention to tasks, quality and speed of work, work consist- ency, and the ability to interact with customers, peers, and supervisors. Find out about the client’s learning styles and learning skill levels. Are he able to learn academic and functional work tasks? Are

10. Career Impact: Finding the Key to Issues Facing Adults with ADHD 199

there any particular instructional or behavioral techniques that are most effective?What are typical learning strategies and the learning rate of the client. These data can come from self-report, and feedback can come from significant others, parents, employers, etc.

Interest inventories will pinpoint client prefer- ences in work and social situations and can be used effectively to ascertain occupational awareness issues for younger clients lacking extensive work experience. It is useful to have objective functional and general academic test scores that are related to work, training, or educational demands. Personal and work temperament characteristics are import- ant factors in determining individual values, such as environmental preferences (e.g., optimal noise and visual stimulation levels, physical demands needed to sustain attention and interest, how much supervision and authority can be handled, and coworker or customer interaction.)

By gathering this kind of additional informa- tion, the clinician and client can focus on and isol- ate what is relevant to the decision-problem. This information comes in handy when the client advo- cates for himself on the job. That is, this informa- tion can form the basis for better decision making. It can also be used to answer questions that signifi- cant others might pose; that is, “What are you going to do about your job? Where are you going to put your energy?” Family members and friends may inadvertently undermine adults with A D H D and believe those ADHD adults are rushing off without thinking things through. They may see this as another wild goose chase, such as seeking the perfect job or the perfect mate. Without meaning to, family and friends can be the harshest critics and biggest pessimists.

By having specificinformation, clients can begin to address these criticisms. With assistance from the therapist, they can clarify career decisions and life objectives. They can more clearly see the payoff for the time, effort, and energy they exert to achieve their goals. This is a good time to have clients write down all their hopes and dreams, to write down all

the known or potential barriers to these dreams, and to begin to identify solutions to those barriers. Creative chaos and free-form thinking are good signs during this phase, indicators that the process is heading in the right direction.

At this stage, it is not necessary to get everything exactly right. Pressures to be exact may impede creativity and cause someone to eliminate a poten- tially great opportunity. The idea is to generate a wish list, with no possibility deemed unachievable or unworthy. The wish list should have every desir- able ingredient the client could ever want from the decision. If the decision or choice is viewed as positive, then why is it so positive?

At this point in therapy, a dose of reality can be inserted into the choice consideration by having the client consider the worst possible outcome, to avoid taking any action that could lead to undesir- able consequences. In Frank’s case, he indicated that he should talk with his wife and children. He wanted to incorporate their input, suggestions, and perspectives into his comprehensive list. This is an important piece in the process, because many deci- sions do have an impact on others, and this must be taken into account. Frank may have a hard time explaining to his children that they can’t go on a family vacation because his decision to start his own business makes money tight. When decisions affect others, the consequences need to be thought through with this in mind. The overall value system of the client should include these perspectives.

By refining the “what if” scenarios, fundamen- tal objectives and goals can become organized and prioritized. Clients who present with a “if it feels good do it” perspective need to be challenged with “means+md” thinking. That is, they may need help to determine if the end justifies the means (more money but less satisfaction and lessjob security). Is job security and long-term stability worth less pay? Clarification at this level is very helpful, and object- ives become clearer and are tied to the client’s value system.

In the next step, the therapist and client explore the “refined” list of choices, questions such as “Can

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you live with that decision, if you have less job security?” or “Can you live with less money if you have more security?” This extra step allows clients to see if they can live with the decision. This is also the time to see if anything has been left out, if anything is unclear, or if anything has been mis- stated. This is the optimal time to incorporate results of any evaluations that may have been com- pleted on the client so that a good match can be found between interests, strengths, and limitations. This will help the clients evaluate their objectives before making a final decision. Special aptitudes or abilities, the impact of the disability on the tasks involved, the ability to perform the essential func- tions of the career, skills or experiences that can facilitate the choice, and barriers to or skills that enhance success are explored.

During this exploration, the client should be true to him or herself. Be sure that work preferences, desires, and needs are fully considered. Identify what really matters to the client. The client should be aware of the internal and external motivating factors influencing his or her decision, including self-fulfillment,money, desire for self-improvement, authority, and the opportunity to do different job tasks.

GENERATING REASONABLE ALTERNATIVES

The next stage of the decision-making process is brainstorming alternatives. While clients’ objectives drive their decisions, there is always more than one side to every problem. The clients decision will be only as good as the best alternative, so it is important to find as many reasonable solutions or alternatives, in case there is a need for a backup plan. Therapeutic professionals need to help the client avoid limiting the full range of alternatives and, as a result, generate alternatives that are too narrowly defined to really bring passion to the vision.

Begin by having the client ask, “How can I achieve my objectives?” This should be done with each individual objective. Asking “Why?” helps

Rob Crawford and Veronica Crawford

bring the end into focus. Asking “HOW?”brings the means into focus-“How do I get there?” The client should develop a set of alternatives first, without judgment or evaluation. Keep the client’s mind open during this process, and have her stay open to all kinds of ideas. Eventually, you will narrow these fluid leads to solid ones. If you see a flaw or shortcoming, don’t point it out at this time to the client. Encourage the client’s “stream of con~ciou~new~h~i,c”h is so often a hallmark of adults with ADHD. Save the analysis and evalu- ation for later. This allows the client to remain in control of the process and compels them to main- tain responsibility for the results.

By keeping client focused, the process is more likely to add depth to the career-planning process and is more responsive to the client’s needs for access to all points of view. For example, let’s look at Frank’s career decision-problem again. Frank investigates labor market data specific to his career aspirations in computer technology. He is now able to look at the economic and techno- logical trends that may affect his work environ- ment. He begins to make a list of occupational clusters of similar or related positions based on his stated interests, abilities, and values. He can begin to study the following alternative: different computer start-up companies; registered software consultants; state and county predictions of job growth and decline; and the entry-level salary and potential for advancement in selected companies offering comparable employment.

By generating a number of viable alternatives, Frank can begin to determine whether he wants to become self-employed or whether he should pursue one of the other alternatives. Generally, the client will come to the conclusion that there is no perfect solution. This also reinforces the notion that it does no good to get too obsessive or to spend too much time worrying about the outcome. If the client can see how careful he has been and how well thought out the plan is, he can have more confidence in the decision. Table 10.1 is an example of the various objectives that Frank might identify and the alter-

10. Career Impact: Finding the Key to Issues Facing Adults with ADHD 201

TABLE 10.1 Objectives and Alternatives Related to the Career-Change Decision-Problem

Objectives

1. Earn higher income
2. Work from home or office
3. Training and management opportunities 4. Paid vacation
5. Comprehensivebenefitpackage

Alternative: Pursue Employment Elsewhere

1. Network with local companies for leads
2. Look into what it takes to be independent consultant
3. Find a mentor
4. Utilize Internet, outplacement firms, and other resources

natives that are reasonable given his particular de- cision-problem.

LIVING WITH THE CONSEQUENCES WITHOUT SUFFERING

In this section, the term consequence is used to describe how one evaluates competing alternatives or decisions. Consequences also refer to how well decisions accomplish specific objectives. The client comes to have clear understanding of the conse- quences inherent in choosing one career path over another. Under collaborative guidance with the therapist, he or she can begin to evaluate choices from this perspective to make sure that the choices are ones that can be lived with.

In Frank’s situation, the consequences of his decisions (and alternatives) are explored. How will the decisions affect him? Frank imagines him- self on a typical day, week, and month to “see” what it might be like. If he had to live out the con- sequences, how would he feel? This process allows Frank to consider the long-term effects of his deci- sion and to gain a better understanding of his decision. Immediate gratification is delayed and more strategic, systematic decisions become possible. Table 10.3 summarizes the objectives he believes are essential to making a smart career choice.

The table includes the top five companies that have been researched. Frank believes these com- panies represent the best available and researched opportunities matching his interests, abilities, and

values. By evaluating the list, Frank decides that while Job E pays more than Job A, it is more import- ant to have flexibility in his schedule than a larger paycheck. He also decides that though Job C offers him flexibility,he couldn’t live on the salary. He also sees that Job A has better benefits. The therapist employs this “comparative” strategy with the client to get him to see if any of the options clearly domin- ates or is clearly inferior. By comparing facts and figures(seeTable 10.3),Frank analyseseachrow and assigns a ranking of each of the consequences. The highest values can then be compared. The retirement benefits (even with lower starting pay) in Job A are more important than the extra day of vacation pay in Job D. Job A also offers management opportunities that are not part of any other package. The therapist begins to help Frank to set up networking opportun- ities where he will spend one to two intense days at each company he determines are the final candi- dates.

By spending time in the environment, Frank can determine if the compromises he has to accept with each choice are something he can live with. The time at each work site provides a good therapist- directed project to do a situational assessment. In the situational assessment, Frank gathers informa- tion about: job descriptions; how he likes the com- mute; the functional use of academic skills; how instructions and training are conveyed; insights into company culture; what types of personality style are displayed by supervisors and coworkers. This on-the-job assessment will give Frank a much better grasp on what life would be like to make a commitment to a given company.

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Rob Crawford and Veronica Crawford

Objectives

Job B Job C

Job D

$3,900 Medium

Logistics

Health, retirement

Job E

$4,200 None

Time management

Health. dental

Salary

Flexible schedule

Develop talent

Vacation (days) Benefits

$4,000 $4,400 $2,800 Medium Low High

Supervise, Computer Operation, computer computer

14 12 10

Health, Health, Health dental, dental
retirement

TABLE 10.2

Job A

Consequences of Career Change Decisions

TABLE 10.3 Ranking Alternatives on Each Objective for Franks Career-Change Decision

Obiectives Job A Job B Job C Job D Job E

Salary 3 1 5 4 2

Flexible 2 4 1 2 5 schedule

Develop 1 3 1 4 5 talent

Vacation 2 3 5 1 3 Benefits 1 3 5 2 3

MANAGING UNCERTAINTIES AND ASSESSING RISK TOLERANCE

In the perfect world, where an adult with ADHD would know what will happen to them before they make a decision, no uncertainty would exist. As it is, a certain amount of chance and calculated risk is inherent in every decision. Frank and his therapist will only be able to know what might happen. Frank and his therapist decide that it would be a good idea to eliminate as much of the random unknowns as possible.

Frank reviews the two basic directions in which his original decision-problem took him: (1) to stay at his original job and take his chance with the new management, or (2) to change his job and accept the best offer of his top five companies. Some of his

uncertainties with staying with his present employer are: “How secure is my present job with the current management?” “Will I have a buy-out option, get a promotion, or be laid off with new ownership?” If he moves and takes a newjob, “How will I deal with the commute?” “Can I handle the responsibilities of management?” “What if I don’t get along with my boss or coworkers?”

He decides to put together a risk-tolerance chart (Table 10.4). In order to decide what is most desir- able among the alternatives he is considering, Frank comes up with three possible outcomes related to his uncertainties if he makes the move to a new com- pany. He also calculates the chances that each one will happening and assigns an “odds-based’’ per- centage to them. For this part of the chart, he has to rely on hisjudgment, to review everything he has

10. Career Impact: Finding the Key to Issues Facing Adults with ADHD 203

TABLE 10.4

Outcome

I get little or none of what I want-No long- term opportunity

I get some of what I want-Long-term opportunity achieved

I get most of what I want-Long-term opportunity achieved/ exceeded

Uncertainties of the Career-Change Alternative

learned so far, and to get input from his family, friends, coworkers, and supervisor. In conversation with his boss, Frank finds another possible alterna- tive:job tryout. He gains approval from his current employer to take an unpaid six-month leave of ab- sence to see if his option is the right choice. His supervisor tells Frank that he might be eligible for rehire if the merger goes through. He assures Frank that he would considered for cross-training if he came back.

Frank decidesto focus on the decision to move to a new company, although he could have stayed with his present employer to see what opportunities the merger might bring. He also could have sought an- other job while staying at his company, but he chose to keep his decision streamlined by focusing on the new opportunity. Now that the decision is made, Frank and his therapist can concentrate on any remaining details that were overlooked, including updating his rksumk, evaluating his personal appear- ance, and working on interview techniques.

CONCLUSION

Clinicians and practitioners can achieve consist- ent results with their clients who are struggling through career changes or looking for methods

and strategies for making solid vocational deci- sions through the use of this planning technique. This approach provides a mechanism for clients to reexamine their interests and clarify what they find is truly useful and valuable to carry forward into the next phase of their working lives. It forces the clients to specify long-term goals and objectives while evaluating various trade-offs. By acknow- ledging that every decision has an element of un- certainty, the client must do a thorough job of analyzing and problem solving the many “what if s” that are part of making a decision.

By performing the community-based fieldwork outside of the controlled clinical setting, the client and the therapist can explore resources in the cor- porate, rehabilitation, and education sectors. By learning how to anticipate changes, the client de- velops better coping mechanisms and problem- solving skills. When problems arise the client has a strategy and method to deal with these issues. When forces are beyond immediate control, the client can still remain focused and can be em- powered with his or her knowledge of how to plan and respond in a flexible manner.

The more opportunities the client has to practice these techniques, the better the quality of the deci- sions that will be made in the future. Clients will come to realize that tough decisions have no more

Chance Least likely, 10%

Most likely, 60% Somewhat likely, 30%

Consequences

Too horrible! No results despite my best. Will have to get old job back or start over.

Good. I would be satisfied for my first plan. More stability, room to grow. Excellent! Great both professionally and personally. I don’t know how I would act getting everything I wanted!

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than one or two decision elements. They will come to see more than one solution to a problem. By maintaining a systematic focus, clients will see how helpful it is to generate alternatives and to evaluate the consequences of each. By getting a clear description of the problem, establishing core objectives, and generating good alternatives on these difficult elements, they can resolve complex decisions with great skill and consistency. Elimin- ating less attractive or functional alternatives be- comes easier. This step-by-step method of decision making reduces impulsive choices and increases successful outcomes that are client centered and therapist supported.

REFERENCES

Campeau, P., & Wolman, J. (1993). Research on self-determin- ation in individuals with disabilities. Palo Alto, CA: American Institutes for Research.

Dickenson, E. (1870). Bartlett’s book ofbusiness quotations (No. 1176, St. 1). Quebec, Canada: Little Brown.

Fellman, W. R. (2000). Finding a career that works for you. Plantation, F1: Specialty Press.

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Field, S., Hoffman, A,, St. Peter, S., & Sawilowsky, S. (1992). Research in self-determination: Interim research report. De- troit: Developmental Disabilities Institute/College of Educa- tion, Wayne State University.

Gerber, P. J., & Reiff, H. B. (1994). Learning disabilities in adulthood. Persisting problems and evolving issues. Stoneham, MA: Andover Medical.

Goleman, D. (1998). Working with emotional intelligence. New York: Bantam Books.

Halpern, A. S. (1993). Quality of life as a conceptual framework for evaluating transition outcomes. Exceptional Children, 59, 48C498.

Hammond, J.,Keeney,R.,& Raiffa,H.(1999).Smart choices:A practical guide to making better decisions. Boston: Harvard Business School Press.

Mithaug, D. (1991). Self-determined kids raising satis$ed and successful children. Lexington, MA: DC Heath.

Nadeau, K. (1995).A comprehensiveguide to attention de$cit in adults. New York: Brunner/Mazel.

Rusch, F., & Chadsey, J. (1998). Beyondhigh school: Transition from school to work. Belmont, CA: Wadsworth.

U.S. Department of Labor (1992). Secretary’s commission on achieving necessary skills. Washington, DC: Author.

Vogel, S. A,, & Reder, S. (1998). Learning disabilities, literacy, and adult education. Baltimore: Brookes.

Wren, C., & Einhorn, J. (2000). Hanging by a twig: Understand- ing and counseling adults with learning disabilities and ADD. New York: Norton.

What Clinicians Need to KnowAbout Legal Issues Relevant to ADHD*

Peter S. Latham, J.D., Patricia H. Latham, J.D.

INTRODUCTION

A D H D may prove legally relevant in a variety of contexts. It may affect education, employment, cus- tody proceedings, criminal prosecutions, and di- vorce. The principal laws under which adults with ADHD may have rights are the Rehabilitation Act of 1973l (RA) and the Americans with Disabilities Act of 1990(ADA).2

These laws are not self-executing. In order to obtain protection, individuals may be required to document their disabilities. Documentation for legal purposes differs from documentation for gen- eral purposes. The purpose for some reports may be to inform the individual concerning his or her dis- abilities, to recommend treatment, such as medica- tion andlor counseling, and to recommend coping strategies. Documentation for legal purposes is or- ganized specifically around establishing a disability that entitles the person to particular accommoda- tions or servicesunder the law.

There are three basic elements of disability docu- mentation: (1) diagnosis, (2) evaluation of impact, and (3) recommendations. Together they establish the existence of a disability, the areas of functioning

Clinician’sGuideto Adult ADHD: AssessmentandIntervention ISBN0-12-287049-2

affected by the disability, and the specific strategies and accommodations in education, testing, work- place, and life in general made necessary by that disability. This chapter will consider when ADHD may be a disability under the law and what the proper methods are of documenting a disability and writing a report for legal purposes.

It is essential for the medical or mental health professional to understand the difference between furnishing an opinion for the purposes of treatment and furnishing one in support of an individual’s legal claim for accommodation under the RA or ADA. In the first case the medical or mental health professional functions only as such; in the latter case, he or she functions as an expert witness in support of the patient’s claim. That is so because the professional will almost certainly be called as a witness should the claim proceed to a lawsuit and then to trial. Thus, the medical or mental health professional may wear two hats in today’s legally oriented environment: healer and potential expert

*The citations used in this chapter (see the Endnotes a t chap- ter’s end) refer to court cases, statutes, and regulations. The referenced materials are available a t law libraries, and most can be accessed on the Internet at http://www.legal.gsa.gov/.

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witness. Let’s begin with an overview of the rele- vant laws.

TWO STATUTES
The Rehabilitation Act of 1973

In the mid-l970s, Congress adopted legislation whose purpose was to end discrimination against individualswithdisabilitiesgenerallyandtoimprove the educational and other services available to them. The first piece of legislation was the Rehabilitation Act of 1973 (RA), which prohibits discrimination against individuals with disabilities in federal em- ployment as well as in government contracts and programs receiving federal financial assistance.

The RA bans discrimination by (1) the United States G~vernment(,2~) contractors with the U.S. G~vernmenta,n~d (3) recipients of federal funds.’ This last provision, popularly known as Section 504, covers all federal grant and aid recipients. Most notably, it applies to most elementary, sec- ondary, and postsecondary educational institu- tions. It also served as the model for the Americans with Disabilities Act of 1990.

The Americans with Disabilities Act of 1990

The Americans With Disabilities Act (ADA) was passed in July 1990 for the purpose of ending discrimination against individuals with disabilities in the area of employment, state and local govern- ment activities, public accommodations, and other public activities.

The ADA was intended to extend the basic dis- ability-based civil rights set forth in the RA to virtually all segments of society. The rights and obli- gations created by the ADA overlap, to some extent, those of the RA. The simplest way to think of the matter is to remember that the RA follows federal dollars. It applies to most federal employment, to

Peter S. Latham and Patricia H. Latham

federal government contractors, and to grant and aid recipients. The ADA applies more broadly.

The ADA prohibits discrimination in three major areas: private employment (Title I), the activities of state and local governments (public schools, employment, licensing, public programs, etc.) (Title II), and access to privately owned places of public accommodation (private schools, except for religiously controlled schools, hotels, theaters, etc.) (Title 111). The Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 apply to most academic institutions and employers.

INDIVIDUAL WITH A DISABILITY Introduction

In the text that follows we will consider whether and under what circumstances an individual with ADHD may be considered an individual with a dis- ability under the RA and ADA. Under these laws an individual with a disability is one who “has a phys- ical or mental impairment which substantially limits one or more of such person’s major life activitie~.”~ Each of these requirements has been the subject of extensivejudicial analysis and are discussed next.

Physical or Mental Impairment

To be covered by the RA and ADA, an individ- ual must first have a physical or mental impair- ment. The term physical or mental impairment includes “any mental or psychological disorder, such as mental retardation, organic brain syn- drome, emotional or mental illness, and specific learning di~abilities.”~

Note that the RAIADA definition expressly in- cludes individuals with “specific learning disabil- ities.” Typical of the many judicial expressions to the effect that ADHD is an impairment under the RAIADA is the statement of the Seventh Circuit in Davidson v. Midelfort Clinic, Ltd.! “There is no

11. What Clinicians Need to Know About Legal Issues Relevant to ADHD 207

dispute that ADD qualifies as an impairment for purposes of the statute.”

ADHD is an impairment under the RA and ADA. However, not every case of ADHD is suffi- ciently severe to constitute a disability under the law. Only those cases in which A D H D substantially limits a major life activity are covered.

Major lifeActivities

The requirement for proof of a substantial limi- tation to a major life activity was recognized in Schneider v. Sun Francisco9. There, a parts store- keeper with ADHD stated in his deposition that he was not substantially limited in any major life ac- tivity and that ADHD did not limit his ability to do the job from which he had been fired. The Court entered summary judgment for San Francisco, holding that he had no disability under the ADA.

The major life activities consist of “caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and work- ing.”” However, the list of major life activities contained in the federal regulations is not exclusive.

The Equal Employment Opportunity Commis- sion (EEOC) has added certain activities, including concentrating and interacting with others, to the list of major life activities its investigators will rec- ognize. The EEOC has issued a pamphlet entitled EEOC Guidance on the Americans with Disabilities Act and Psychiatric Disabilities (Guidance). The purpose of this document is to set forth the com- mission’s position on this topic and to provide guidance to its personnel in enforcing Title I (con- cerning employment) of the ADA. In it, the EEOC has added thinking, concentrating, and interacting with others, as well as sleeping, to the list of major life activities its investigators will recognize.

In Sutton v. United Air Lines, Inc.,” discussed hereafter, the Court ruled that “[nlo agency. ..has been given authority to issueregulations implement- ing the generally applicable provisions of the ADA,” and therefore, the helpfulness of these regulations

and guidance is questionable. Nonetheless, they have had a major impact in the administration of the RAIADA; and because this is so, they may yet provepersuasivetothecourts.Wewillbrieflyreview major life activities that may be limited by ADHD and/or related impairments and that have been ad- dressed by the EEOC and/or the courts.

Learning

Learning is a major life activity in which many individuals with ADHD may be substantially limited. However, in order to meet the substantial limitation requirement, it is necessary to show that learning truly is substantially limited. In Price v. The National Board of Medical Examiners,12 for example, the Court found that three medical stu- dents, who had no history of substantial academic difficulties but had been diagnosed by responsible professionals as having learning disabilities and/or ADHD, were not individuals with disabilities under the ADA because their impairments did not substantially limit them in a major life activity of learning when compared to most people. Accord- ingly, the Court denied them an injunction requir- ing additional time on the United States Medical Licensing Examination (USMLE).

The Tenth Circuit, in McCuinness v. University of New Mexico School ofMedicine,13 ruled that Mc- Guinness, a medical student, had no disability be- cause he failed to show that his mental impairment (anxiety) “impedes his performance in a wide variety of disciplines, not just chemistry and physics.”

In Leisen v. City of Shelbyville, Leisen v. City of Shelby~ille,’t~he Seventh Circuit reached a similar result. There, the Court held that Leisen, a female firefighter who was unable to complete a required paramedic course because of depression, was not an individual with a disability. Leisen never showed that her depression “substantially limited” a major life activity. The Seventh Circuit said:

The mere fact that Leisen was having obvious diffi- culty in passing the course for paramedic certification does not show that she was substantially limited in the

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major life activity of learning, any more than the fact that a particular individual might not be able to pass a course in physics or philosophy would allow an inferencethat all learning activity was substantially limited.

The Court went on to note that “Leisen success- fully completed other training courses around the same time she was repeatedly failing the paramedic course; she successfullymaintained her EMT certi- fication; and she passed most of the courses in the last paramedic program even while she was suffer- ing from all the stress she described.” Thus, proof that learning is substantially limited requires a showing that learning is substantially limited in a broad sense and not just in one course or program.

Reading and Writing

Some courts have broken learning down into components such as reading” and writing.16When learning is thus subdivided it becomes easier for one to show that one component of learning has been substantially affected. However, the Supreme Court has not indicated any inclination to break major life activities into components.

Working

Working is treated differently from all other major life activities for purposes of considering whether an individual with an impairment is sub- stantially limited. In order to determine whether a substantial limitation on working exists, the indivi- dual’s impairment must bar him or her from signifi- cant classesofjobs andnotjust aparticularjob. Only disabilitieswith the former (and broader) impact are considered substantially to limit working.

In Davidson v. Midelfort Clinic,Ltd.” the Seventh Circuit addressed the application of this rule to an individual with ADHD. That case involved Barbara Davidson, a licensed psychotherapist whose em- ployment with the Midelfort Clinichad been termin- ated for cause. Ms. Davidson’s ADHD was described by the Court that viewed it as “a chronic psychological disability resulting from a biochem-

Peter S. Latham and Patricia H. Latham

ical imbalance. The disorder can interfere with one’s cognitive processes, including the ability to concen- trate, to learn, to organize one’s thoughts, to verbal- ize them, and to formulate explanations.”

In Ms. Davidson’s case, ADHD substantially limited her ability to perform all the tasks required of a psychotherapist at the Midelfort Clinic. The Court found that therapists at the clinic were “re- quired to dictate their patient notes for transcrip- tion by other staff members and inclusion in the patient’s file.” However, ADHD made it more “difficult for Davidson to organize her thoughts without first writing them down on paper,” a fact that led her “to write out her notes before dictating them, an obviously time-consuming process.” As a result, Ms. Davidson fell unacceptably behind in her dictation of patient notes and was fired for it. She sued under the ADA.

The Court readily agreed that ADHD was an impairment under the ADA. The Court said: “There is no dispute that ADD qualifies as an impairment for purposes of the statute.” However, the Court then went on to find that Ms. Davidson’s ADHD did not limit her substantially in working:

At most, the evidence in this case suggests as a result of ADD, Davidson was unable to perform her job at Midelfort. Davidson has come forward with no evidence from which one might reasonably infer that ADD pre- cluded her even from holding other comparable positions as a therapist. Indeed, by her own account, the principal reason for Midelfort’s decision to discharge her was her slowness in completing her dictation. Whatever import- ance Midelfort may have attached to timely dictation, that was only one aspect of Davidson’s employment with Midelfort, and the record does not suggest that ADD imposed other limitations on her ability to function effec- tively in her role as a counselor… .Moreover, so far as the ability to dictate her notes is concerned, Davidson has made no showing that this is a skill that other counseling positions require. It strikes us as somewhat unlikely that all employers of psychotherapists demand that one’s notes be dictated for transcription by other employees, particularly with computers becoming an omnipresent fixture in the workplace. We can only speculate about that, however, because Davidson has given us no evi- dence on this point. She has shown only that Midelfort required her to dictate her notes and deemed her compe-

11. What Clinicians Need to Know About Legal Issues Relevant to ADHD 209

tence in that regard to be subpar. [Citations and foot- notes omitted.]

The Supreme Court has viewed working (as a major life activity) with skepticism. In Sutton v. United Air Lines, Inc.,” the Court noted that, be-

cause “the parties accept that the term ‘major life activities’ includes working, we do not determine the validity of the cited regulations.” The Court nonetheless commented “that there may be some conceptual difficulty in defining ‘major life activ- ities’ to include work.”

Concentrating

An individual might be considered to have a substantial limitation in the ability to concentrate “if s/he was easily and frequently distracted, mean- ing that hidher attention was frequently drawn to irrelevant sights or sounds or to intrusive thoughts; or if s h e experienced hidher ‘mind going blank’ on a frequent basis.””

However, the Tenth Circuit has ruled that con- centration is not a major life activity. In Pack v. KMart Corporation,20 Pack, an employee for 18 years, was transferred to the job of pharmacy tech- nician. She developed major depression, moderate to severe in nature, which caused her to make “technical errors in the pharmacy, including mis- labeling prescriptions and incorrectly entering pre- scription data into the pharmacy computer,” for which she was fired. She sued under the ADA, contending that she was substantially limited in the major life activities of concentrating and sleep- ing. The Court held that, while sleeping is a major life activity, Pack failed to prove that she was sub- stantially limited in it, and concentrating was no major life activity at all. The Court said:

In deciding whether a particular activity is a “major life activity,” we ask whether that activity is significant within the meaning of the ADA, rather than whether that activity is important to the particular individual. . . .We hold that sleeping is a major life activity, but concen- tration is not. Sleeping is a basic activity that the average person in the general population can perform with little

or no difficulty, similar to the major life activities of walking, seeing, hearing, speaking, breathing, learning, working, sitting, standing, lifting, and reaching. . . . How- ever, concentration is not itself a major life activity. Con- centration may be a significant and necessary component of a major life activity, such as working, learning, or speaking, but it is not an “activity” itself.

In reaching this result, the Court noted that, while “the EEOC’s guidance may be entitled to some consideration in our analysis, it does not carry the force of law and is not entitled to any special deference.”

Ability to Interact with Others

An individual would be considered to have a substantial limitation in the ability to interact with others “if hidher relations with others were characterized on a regular basis by severe prob- lems, for example, consistently high levels of hos- tility, social withdrawal, or failure to communicate when nece~sary.”T~h~e courts have divided on the question of whether interaction with others is a major life activity.22

Thinking

At least one court has held thinking to be a major life activity. In Schumacher v. Souderton Area Sch. D i ~ t . t,h~e ~Court held that a middle school teacher would be considered an individual with a disability under the ADA if she could show that she had ADHD that substantially limited her ability to engage in “cognitive thinking,” a major life activity recognized as such by the Court. In order to establish disability status, ADHD must substantially limit a major life activity, such as learning or working.

Substantially limited

Not every impairment that affects a major life activity is a disability under the ADA. Only those whose effects substantially limit a major life activity

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can be considered disabilities. The concept of sub- stantial limitation has been elaborated by regula- tions and court decisions. The regulations provide that an individual with a substantial limitation is:

(i) Unable to perform a major life activity that the average person in the general population can perform; or (ii) Significantlyrestricted as to the condition, manner or duration under which an individual can perform a particular major life activity as compared to the condi- tion, manner, or duration under which the average person in the general population can perform that same

major life a~tivity.’~

Questions have arisen as to when and how the limiting effects of an impairment should be meas- ured in determining whether they are substantial in nature.

When Measured

Whendo you measure a disability’sseverity?Do you measure the severity with or without consider- ing the effects of a person’s coping strategies or the effects of medication? Prior to 1999, most courts held that, under the ADA, the severity of an im- pairment is to be measured without considering the effects of a person’s coping strategies, medication, or prosthetic devices. In the ADA. In Sutton v.

UnitedAirLines,I~c.,~th’eSupremeCourtrejected those cases.
“ Karen Sutton and her twin sister, Kimberly, had

severe myopia,” which was correctable to “20120 or better” with glasses or contact lenses. Without these, however, both sisters “effectively” could not “see to conduct numerous activities, such as driving a vehicle, watching television or shopping in public stores.” Nonetheless, the sisters applied to United Airlines for employment as commercial pilots. The sisters met United’s requirements for “age, educa- tion, experience, and FAA certification qualifica- tions” but not United’s vision standards that required “uncorrected visual acuity of 201100 or better.” When United refused to consider their employment applications, they sued under the ADA. The sisters lost in both the District Court

Peter S. Latham and Patricia H. Latham

and the Tenth Circuit Court of Appeals. They then asked the U.S. Supreme Court to hear their case.

In the Supreme Court, the sisters argued that applicable regulations, the EEOC’s “Interpretive Guidance,” and a “similar guideline” issued by the Department of Justice, require that “[tlhe de- termination of whether an individual is substan- tially limited in a major life activity must be made on a case-by-casebasis, without regard to mitigat- ing measures such as medicines, or assistive or prosthetic devices.” Applying these rules, the sisters’ uncorrected vision would have been a dis- ability under the ADA.

The Supreme Court nonetheless ruled for United Airlines, seven to two, concluding that Congress never intended the ADA to protect, as disabled, those who, like the sisters, were able to “function identically to individuals without a simi- lar impairment,” when employing “mitigating measures such as medicines, or assistive or pros- thetic devices.” When enacting the ADA, the Court reasoned, Congress found that “some 43 million Americans have one or more physical or mental disabilities, and this number is increasing as the population as a whole is growing older.”26

Because it is included in the ADA’s text, the finding that 43 million individuals are disabled gives content to the ADA’s terms, specificallythe term “disability.” Had Congress intended to include all persons with corrected physical limitations among those covered by the Act, it undoubtedly would have cited a much higher number of disabled persons in the findings. [The Court noted that, under a more liberal definition of disability, the ADA could be read to include as many as “160 million dis- abled.] That it did not is evidence that the ADA’s cover- age is restricted to only those whose impairments are not mitigated by corrective measures.

The Court then stated its ruling:

We conclude that respondent is correct that the ap- proach adopted by the agency guidelines-that persons are to be evaluated in their hypothetical uncorrected state-is an impermissible interpretation of the ADA. Looking at the Act as a whole, it is apparent that if a person is taking measures to correct for, or mitigate, a physical or mental impairment, the effects of those

11. What Clinicians Need to Know About Legal Issues Relevant to ADHD 211

measures-both positive and negative-must be taken into account when judging whether that person is “sub- stantially limited’ in a major life activity and thus “dis- abled’ under the Act.

Justice Ginsburg wrote a concurring opinion. She noted that Congress’ purpose in adopting the ADA was “to restrict the ADA’s coverage to a confined, and historically disadvantaged, class” ofindividuals, specificallythose who, by reason of their disabilities, had been “subjected to a history of purposeful un- equal treatment, and relegated to a position of polit- ical powerlessness in our society.”27The “inclusion of correctable disabilities within the ADA’s domain would extend the Act’s coverage to far more than 43 million people. And persons whose uncorrected eye- sight is poor, or who rely on daily medication for their well-being, can be found in every social and economic class; they do not cluster among the polit- ically powerless, nor do they coalesce as historical victims of discrimination.”

The Supreme Court applied its reasoning in a companion case to Sutton, Murphy v. United Parcel Service, Inc.28There, the Court ruled, on the same grounds as in Sutton, that an individual with hypertension (high blood pressure) that was “ap- proximately 2501160” without medication was not a disability under the ADA because, with medica- tion, his “hypertension does not significantly re- strict his activities a n d . . . in general he can function normally and can engage in activities that other persons normally do.” The Court affirmed the dismissal of Murphy’s claim.

The Court reached the same result with respect to compensatory strategies in a related case, Albert- sons, Inc. v. Kirkingb~rg.~~

Together, these three cases hold that the effects (both positive and negative) of prosthetic devices (Sutton), medicines (Murphy), and compensatory strategies (Kirkingburg) must be considered when determining whether an individual has an impair- ment that substantially limits a major life activity and is therefore covered by the ADA.

Lower court decisions have made it clear that the severityofADHDmustbemeasuredafterconsider-

ingthepositiveandnegativeeffectsofmedication.In Blackston v. Warner-Lambert CO.,~’the Court held that a person with ADHD whose condition is cor- rected by medication is not an individual with a disability within the meaning of the ADA. Blackston admitted, and his physician confirmed, that Black- ston’s ADHD, when treated with medication, did not present in such amanner as to substantially limit him in the major life activities of thinking and working.

In Schumacher v. Souderton Area Sch. Di~t.,~’ the Court discussed the impact of Sutton on a middle school teacher’s claim that her ADHD sub- stantially limited her ability to engage in “cognitive thinking,” eating, and sleeping, major life activities recognized as such by the Court.

Therefore, under Sutton, to determine whether her continuing impairment qualifies as a disability, this court must consider whether Schumacher’s ability to engageinthesemajor lifeactivitiesissubstantiallylimited by ADHD, even in its corrected state, that is, even when she properly takes her medication as prescribed….If medication controls ADHD such that it enables Schu- macher to think, sleep, and otherwise function as would the average person, just as corrective eyewear enables a person with myopia to attain 20/20 vision, Schumacher would not have a disability under [the ADA]. However, this court is unable to say, at this stage, that ADHD, controlled by medication, still does not substantially limit Schumacher’s ability to perform these major life activities and still does not render her disabled within the meaning of the ADA….The Amended Complaint alleges that Schumacher remains limited in these activ- ities and those allegations are accepted as true for present purposes. . . . Schumacher sufficientlyhas pled a disability under [theADA].

Considering the total effects of the impairment, together with those of the prosthetic devices, medi- cations, and strategies, makes the ADAIRA ap- proach much closer to that used in the Social SecurityAct.InAndersenv.A~felfo,r~e~xample, the Court held that ADHD that is “remedied” by medication is not an SSI disability, because, under that law, any medical condition that is remedied by surgery, treatment, or medication is not disabling. Only individuals with ADHD that substantially

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limits a major life activity are considered disabled under the RA and ADA. The evaluation of ADHD’s impact must take into account the positive and nega- tive effects of any medication and compensatory strategies.

How Measured

Human attributes such as intelligence, beauty, and athletic prowess are often measured by com- paring those of the individual in question with those of other people. Impairments under the ADA are also measured by comparing those of the individual against a norm. However, while there is universal agreement on this point, there are divisions among judges, attorneys, and other professionals as to just what norm an impair- ment should be measured against. Several methods of comparison have been used under this stand- ard.

Price. v. The National Board of Medical Exam- i n e r ~co~ns~idered the request of three medical stu- dents who had no history of substantial academic difficulties but had been diagnosed by responsible professionals as having learning disabilities and/or ADHD, for an injunction requiring additional time on the United States Medical Licensing Examin- ation (USMLE), Step 1. The Court ruled that the students were not individuals with disabilities under the ADA because their impairments did not substantially limit them in a major life activity when compared to most people. The Court de- scribed the medical students thus:

First, each plaintiff has some learning difficulty. Second, each of the students has a history of significant scholastic achievement reflecting a complete absence of any substantial limitation on learning ability. Further, this record of superior performance is corroborated by standardized test scores measuring cognitive ability and performance. Finally, there is a complete lack of evidence suggesting that plaintiffs cannot learn at least as well as the average person. That is, these students do not suffer from an impairment which substantially limits the life activity of learning in comparison with most people.

Peter S. Latham and Patricia H. Latham

Based on these findings,the Court concluded that the medical students were not protected under the ADA. The Court focused on comparing bottom-line performance to the average person’s performance.

If the courts were to focus on bottom-line per- formance compared to the average person, it would be difficult, under this test, to show the requisite impact at the college level and even more difficult to do so at the graduate school level, since the average person does not complete college.

The Average Member of the Population

Proof of substantial limitation when compared to the average member of the population is essen- tial. Who is the “average person”? These questions are of minor importance for persons with physical impairments, such as mobility, vision impairments, and hearing impairments, which can be measured in individual cases with a high degree of reliability and statistics compiled to generate a norm. This is less so for learning, attentional, and psychiatric impairments.

In DeMar v. Car-Freshner C o r ~ .t,h~e ~Court denied the claim of an employee with ADHD be- cause that essential proof was not forthcoming: “Plaintiff mistakenly leaps to the conclusion that because he has ADHD, his ability to concentrate is substantially limited as compared to the average person.”

Sevigny v. Maine Education Association- National Education A ~ s o c i a t i o nre~a~ched a similar result. The magistrate hearing the case ruled that the plaintiff had failed to establish the existence of a disability. Specifically, the plaintiff failed to show that the conditions of his life with ADHD and depression were different from those of the average member of the general population. Noting that “Plaintiff has presented evidence that these condi- tions affect his ability to communicate, focus, and sleep,” the magistrate observed:

It is clear that Plaintiff has had to adopt particular methods of coping with his lack of focus and communi- cation difficulties, but he has apparently done so success-

11. What Clinicians Need to Know About Legal Issues Relevant to ADHD 213

fully. There is nothing remarkable about developing tools “about taking notes and keeping track of things using a calendar in a different way and initiate conversa- tions more successfully,”or having to use “a lot of sort of detailed trial-and-error problem solving.” Quite likely Plaintiffs impairments have simply forced him to acquire skills which would benefit most people.

Most glaringly, however, Plaintiffs only attempt to compare the manner in which he has to communicate, think, or sleep with the manner in which the average person can do these things is the one paragraph stating that “[tlhinking, concentrating, and communicating are activities that the average person in the population can d o with little or no difficulty.” While this may be true, it says nothing about how well the average person does them with little or no difficulty.. . .

Plaintiff is asking the Court to conclude from the mere fact that his conditions afect these aspects of his life that he is substantially limited in his abilities when compared to the average person. There is no evidence in the record to support this conclusion. [Citations to the trial record omitted.]

In Jones v. Men’s Wearho~seth~e~Court con- sidered the case of a former employee with ADHD who sued his employer under the ADA. The Court found against the former employee,holding that (1) the existence of some behavioral difficulties arising from ADHD and the medications that address it does not amount to a substantial limitation on the ability to care for oneself, (2) difficultyrecalling some wordsdoesnotamounttoasubstantiallimitationon the ability to speak, and (3) the existence of excellent work evaluations and a high collegeGPA showsthat the former employee experienced no substantial limitation on the ability to learn.

These cases hold that the ADA requires a com- parison between the individual’s performance of major life activity and that of the average member of the population. They recognize that the average is not the perfect person and does not perform these activities in aperfect manner. As a result, the ADA requires proof not only of a substantial limitation or deviation but of a deviation from a benchmark that itself may have significant imperfections. In evaluating the impact of ADHD, the individual’s ability to perform a major life activity must be compared to that of the average member of the

population, recognizing that the average member’s ability to perform those activities is imperfect.

The RA and ADA do not protect all individuals with disabilities, only those who are “otherwise qualified” for the educational program, job, or license at issue.37 However, the very facts that show that an individual is one with a disability can also show that the individual is not otherwise qualified.

In Robertson v. Neuromedical Center,38 for example, the Fifth Circuit upheld the termination of a neurologist with ADHD. Holding that there was no duty to accommodate Robertson in his medical practice, the Court said:

We agree with the district court’s conclusion that “[c]onsidering the limitations on plaintiffs abilities caused by ADHD, the type of work he is engaged in, the interests of NMC in running its business, and most importantly, the safety of the patients at NMC . . . plaintiff cannot establish a prima facie case that he could continue in his position as a neurologist because accommodation is not possible in these circumstances.”

Robertson posed a “direct threat” to the health and safety of others in the workplace. Robertson’s short-term memory problems had already caused various mistakes to be made in patients’ charts and in dispensing medicine. Most significantly, Robertson voiced his own concerns about his ability to take care of patients, stating that it was onlyarria~~oerLimebecoreheseriouslyhur~some- one. In light of this evidence, we agree with the district court’s conclusion that any accommodations in this case would be unjustified from the standpoint of the basic medical safety of Dr. Robertson’s patients.

The very proof that showed Robertson to have ADHD amounting to a substantial limitation in a major life activity also showed that he was not qualified to perform his job.

InBercovitchv.BaldwinSchool,I ~ c .th,e~U~nited States Circuit Court of Appeals for the First Circuit held that Jason, a student with ADHD, was not entitled to “be exempted from the normal operation

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of the school’s disciplinary code” as a reasonable accommodation under either the ADA or the RA! The proposed accommodation was that the student “only be suspended after at least three warnings, and then only for the remainder of the day.” This modi- fication would eliminate “the normal progressive discipline built into the school’s code” and would have prevented the school “from suspending Jason, as it would any other student, for repeated disruptive behavior.” The Court ruled that “[tlhis was an alter- ation of a fundamental requirement of the school’s academic program and as such is not required by the ADA,” or the RA, which the Court viewed as “im- posing parallel requirements.” Jason’s behaviors had rendered him not otherwise qualified to attend the school. These problems exist with respect to licensing as well.

In the Spring of 1997, the Subcommittee on the Constitution of the House Committee on the Judi- ciary held a hearing regarding the “Application of the Americans with Disabilities Act to Medical Licensure and Judicial Officers.” Testifying on behalf of the Federation of State Medical Boards was Ray Q. Bumgarner, Executive Director, State Medical Board of Ohio.

The Federation stated that requests for medical licensure testing accommodations are skyrocketing and are based primarily on learning disabilities and ADHD. According to the Federation testimony, anyone who asks for accommodations may put his or her competence to practice medicine legitim- ately at issue.

The Federation had this to say about ADHD and learning disabilities:

Many disabilities, such as LD and ADD/ADHD, are life-long conditions which impact and impair one’s func- tioning in a pervasive way. Any expert in the fields of these disabilitieswill confirm that they do not limit their impact solely to the context of standardized multiple- choice examinations. An individual with ADD/ADHD, for example, may be expected to have difficulty focusing and to be easily distracted or unable to concentrate in the presence of distractions in a testing context, but would be expected to encounter these same difficulties in other contexts as we11.40

Peter S. Latham and Patricia H. Latham

Quoting from ADA documentation provided by applicants with A D H D and learning disabilities, the Federation advised Congress that

it would be relevant to a medical licensing authority to know that the responding applicant needed to be tested in a room separate from other people with double the amount of testing time because she asserted that “[qn her day-to-day work, she is quite distractible so that it is hard for her to work or study in an environment in which there are many other people,” or because “[nloise, others talking, rustling papers, extra movement around him, etc. distract him and cause him to lose focus,” or because he is “often having difficulty sustaining attention in tasks (especially in the area of reading), often having difficulty organizing tasks and activities, often avoiding or reluc- tant to engage in tasks that require sustained mental effort, and often not responding when spoken to directly. He is very easily distracted by extraneous stimuli, and quite frequently loses things necessary for an activity.”

While knowledge of the need for such accommoda- tions in a context requiring intellectual functioning and decision making should not necessarily lead to the denial of a license, it might logically lead to further and appro- priate inquiry as to the setting in which the physician intends to practice and the accommodations or modifica- tions, if any, to be made in the practice setting to enable the physician to perform the essential functions of med- ical practice in a safe and competent manner.41[Em- phasis added; footnotes omitted.]

Yet some physicians with dyslexia report diffi- culty with heavy reading requirements that call for rapid reading ofcomplexmaterial but report no diffi- culties in their clinical work. Other physicians with ADHD report difficultywith concentration and pro- cessing lengthy written tests but report receiving excellent evaluations in performing the actual work of a physician in their residencies. Since learning disabilitiesand/or ADHD present in a widely differ- ent manner in different people, applying general concepts about these disorders in individual cases would be unsound. Individual performance in clini- cal settings provides the best evidence of competence and should be determinative. The ADA protects only qualified individuals with disabilities. A quali- fied individual with a disability is one who can meet academic or job-related requirements with or with- out a reasonable accommodation.

11. What Clinicians Need to Know About Legal Issues Relevant to ADHD 215

THE RIGHT TO REASONABLE ACCOMMODATION

In General

Once an individual has shown that he or she is a qualified individual with a disability, the RA and ADA mandate that the individual be provided on request with reasonable accommodations in the academic and employment environments.

Reasonable accommodations are of three general types: (1) those required to ensure equal opportunity in the process of applying for admission to an aca- demic program or for employment, (2) those that enable the individual with a disability to perform the essentialfeaturesofacourseofstudyorajob,and(3) those that enable individuals with disabilities to enjoy the same benefits and privileges, in both aca- demic andjob situations, as those available to indi- viduals without disabilities. The first two of these are the most important for purposes of this chapter.

Academic Accommodations

Academic accommodations are those modifica- tions to the nonessential features of an academic program that will give to a qualified individual the opportunity of obtaining the same educational be- nefits as individuals without disabilities. These may include taped texts, interpreters or other effective methods of making orally delivered materials avail- able to individuals with hearing impairments, brailled or large-print texts or qualified readers for individuals with visual impairments and learn- ing disabilities, classroom equipment adapted for use by individuals with manual impairments, and other, similar services and actions.42

Workplace Accommodations

Workplace accommodations are those modifica- tions to the nonessential features of a job that will

enable a qualified individual to perform the essen- tial features of that job.

The EEOC has suggested that some or all of the following may be reasonable accommodations for individuals with psychiatric disabilities. They are of particular interest to many individuals with learn- ing disabilities and ADHD.

Time off: Use of accrued paid leave, or additional unpaid leave for treatment or recovery related to a disability. Occasional leave (e.g., a few hours at a time, or a leave of absence may prove appropriate).

Modified work schedules.
Physical changes to workplace or equipment. These might include room dividers, partitions, soundproofing, or visual barriers, accommodations recommended for “individuals who have disability-related limitations in concentration.” Moving the individual to a quieter location, lowering the pitch of telephones, or permitting use of headphones to block distractions are also possibilities.
Modification of a workplace policy. The EEOC suggests that “it would be a reasonable accommodation to allow an individual with a disability, who has difficulty concentrating due to the disability, to take detailed notes during client presentations even though company policy discourages employees from taking extensive notes during such sessions.” Adjusting supervisory methods to ensure that assignments, instructions, and training are delivered “by the medium that is most effective for a particular individual (e.g., in writing, in conversation, or by electronic mail).” Increased feedback and structure are also reasonable accommodations.
However, employer monitoring to ensure that required medications are taken is not a reasonable accommodation.
Job coaches. The EEOC recommends the use

ofatemnorarviobcoachtoassist in the traininn

iJv

216

Peter S. Latham and Patricia H. Latham

of a qualified individual with a disability as a reasonable accommodation.
Reassignment to a vacant position must be considered as a reasonable accommodation when accommodation in the present job would constitute an undue hardship.

Selecting the Accommodation

may require the revelation ofmost or all of his or her medical record. The probability of full disclosure increases as the parties approach litigation. Medical recordsareoftenrequiredtobeproducedinacasein which the impairment of the individual is at issue.

Accordingly, the individual and his or her mental health professional should take the time to consider a worst-case scenario in which the claim is refused and litigation becomes necessary. Is the individual comfortable with disclosure? Is the pro- fessional comfortable with defending the accuracy and thoroughness of his or her professional judg- ment? Qualified individuals with disabilities are en- titled to reasonable accommodations. Reasonable accommodations are of three general types: (1) those required to ensure equal opportunity in the process of applying for admission to an academic program or for employment, (2) those that enable the individual with a disability to perform the es- sential features of a course of study or ajob, and (3) those that enable individuals with disabilities to enjoy the same benefits and privileges, in both aca- demic and job situations, as those available to indi- viduals without disabilities.

THE PROFESSIONAL’S OPINION

At the beginning of this chapter we noted that there are three basic elements of disability documen- tation:(1)diagnosis,(2)evaluationofimpact,and(3) recommendations. Together they establish the exist- ence of a disability, the areas of functioning affected by the disability, and the specific strategies and ac- commodations in education, testing, workplace, and life in general made necessary by that disability.

The professional’s report or opinion should in- clude:

0 Identification of the individual’s physical or mental impairment, using the current version of the Diagnostic Statistical Manual (DSM) where possible. (While not legally required, judges and attorneys are used to referring to this volume.)

The process of selecting a reasonable accommo- dation is an interactive one. In Beck v. Universityoj Wisconsin,43the Seventh Circuit Court of Appeals considered the case of a secretary who “suffered from osteoarthritis and depression.” Following a three-month medical leave, she disclosed her disabil- ities and supported them with letters from her doctor. However, she refused to sign a release allowing the university to obtain further informa- tion from her doctor and provided no further infor-

mation about her need for accommodations. Adjustment to her workload wasthe only accommo- dation specifically requested by the doctor, and it was granted. Following another medical leave, the university offered her old job back. When she insisted on another job, she was fired. She brought suit under the ADA. The Seventh Circuit affirmed the trial court’s decision against the secretary, reasoning that the ADA and its regulations contem- plate an interactive process to identify appropriate accommodations. The employer must provide infor- mation about its facilities and equipment, and the employeemust provide information about his or her disability. The Court stated: “Once an employer knows of an employee’sdisability and the employee has requested reasonable accommodations, the ADA and its implementing regulations require that the parties engage in an interactive process to deter- mine what precise accommodations are necessary.” The same rules apply to academic accommodations.

The Beck case illustrates a common dilemma. Oftenanindividualwillseekthesupportofhisorher medical or mental health professional to obtain an accommodation without realizing that the request

11. What Clinicians Need to Know About Legal Issues Relevant to ADHD

217

F Descriptionoftheimpairment’simpactonthe individual’s ability to perform one or more of the major life activities listed earlier in the chapter. Usually, these will be learning or working. A description of the positive and negative eects of any medication and compensatory strategies may be addressed.

F Comparisonoftheindividual’sabilityto perform the identi®ed major life activity or activities compared to the average member of the population. Bear in mind that the average person may perform the life activity in question imperfectly. The comparison should demonstrate that the limitation is a substantial one.

F A demonstration that the disability described does not render the individual unquali®ed for the academic program or job.

F Recommendations concerning the appropriate accommodation necessary to address the disability described. Bear in mind that necessity and not personal preference is the standard to be met.

CONCLUSION

Under the RA and ADA, protection is extended to quali®ed individuals with disabilities. These are persons with physical or mental impairments that substantially limit one or more major life activities. An individual with a disability is quali®ed if he or she can meet the essential requirements of an aca- demic program or job with or without a reasonable accommodation.

The professional’s report must supply the three basic elements of disability documentation: 1) diag- nosis, 2) evaluation of impact, including the positive and negative eects of medication, if any, and 3) recommendations. Together they establish the exist- ence of a disability, the areas of functioning aected by the disability, and the speci®c strategies and ac- commodations in education, testing, workplace, and life in general made necessary by that disability.

NOTES

1. 29 U.S.C. § 701 et seq.
2. 42 U.S.C. § 12101 et seq.
3. 29 U.S.C. § 791.
4. 29 U.S.C. § 793.
5. 29 U.S.C. § 794.
6. 29 U.S.C. § 706 8) B); 42 U.S.C. § 12102 2). 7. 29 CFR § 1613.702 b).
8. 133 F.3d 499 7th Cir. 1998).
9. 1999 WL 144878 N.D. Cal. Mar. 10, 1999).

10. 29 C.F.R. § 1630.2 I); 29 C.F.R. pt. 1630 app. § 1630.2 I). 11. 527 U.S. 1031 1999).
12. 966 F. Supp. 419 S.D. W.Va. 1997).
13. 170F.3d974 10thCir.1998),cert.denied,119S.Ct.1357 1999). 14. Docket No. 97-2575 7th Cir. August 31, 1998).

15. Bartlettv.NewYorkStateBoardofLawExaminers,156F.3d 321 2d Cir. 1998), vacated and remanded, N.Y. State Bd. of Law Examiners v. Bartlett U.S. June. 24, 1999) No. 98-1285).

16. Sellar v. State of Maine; Civil No. 97-0208-B D. Maine June 24, 1998) MAJ).

17. 133 F.3d 499 7th Cir. 1998).
18. 527 U.S. 1031 1999).
19. Guidance, at p. 10.
20. Docket No. 97-7120 10th Cir. 1998). 21. Guidance at p. 10.

22. Soileau v. Guilford of Me., Inc.; 105 F. 3d 12 1st Cir. 1997); Gilday v. Mecosta County; Docket No. 96-1571 6th Cir. September 2, 1997).

23. Docket No. 99-1515 E.D. Pa. Jan. 21, 2000). 24. 29 C.F.R. §§ 1630. 2 j) 1) i)± ii).
25. 527 U.S. 1031 1999).
26. 42 U.S.C. §§ 12101 a) 1).

27. Citing 42 U.S.C. § 12101 a) 7).
28. Murphy v. United Parcel Service, Inc., 527 U.S. 516 1999). 29. 527 U.S. 555 1999).
30. 2000 WL 122109 N.D. Ala. Jan. 26,2000).
31. Docket No. 99-1515 E.D. Pa. Jan. 21, 2000).
32. 1999 WL 39518 E.D. La. Jan. 29, 1999).
33. 966 F. Supp. 419 S.D. W.Va. 1997).
34. 1999 WL 34973, 4 N.D.N.Y. Jan. 14, 1999).
35. Docket No. 98-0090-B D. Me. 1999) MAG).
36. 1999 WL 134210 N.D. Tex. Mar. 10, 1999).
37. 29 U.S.C. § 794 a); 42 U.S.C. § 1211.
38. Docket No. 97-31169 5th Cir. December 3, 1998), cert.

denied, Docket No. 98-1377 May 3, 1999). 39. 133 F. 3d 141 1st Cir. 1998).
40. Bumgarner Test, p. 21.
41. Bumgarner Test, pp. 21, 22.
42. 28 CFR § 36.309 c) 3).
43. 7th Cit. 1996)

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Peter S. Latham and Patricia H. Latham

REFERENCES

Latham, Peter S, J. D. and Patricia H., J. D., ATTEMTION DEFICIT DISORDER AND THE LAW, 2ND ED, JKL Communications (2000).

Latham, Peter S, J. D. and Patricia H., J. D., DOCUMENTA- TION AND THE LAW, JKL Communications, (1998).

Making Marriages Work for individuals with ADHD

Patrick J. Kilcarr, Ph.D.

Ispeak ofjouvneys because ofcouvse we aye all ofus on ajouvney ouvselves. The compavison of life to a voad is a vevy ancient one, and you and I aye tvavelevs along that voad whethev we think of it that way OY not, tvaveling

fvom the unknown into the unknown. When we aye on ajouvney, what is veal is not so much the vole we play, the mask we weav, in the place that we aye leaving, and not even the voles we will soon be called on to play when we get to the place wheve we aye going. In othev wovds, tvavel can be a vevy unmasking expevience, bvinging us suddenlyface toface with ouvselves-as when we aye gazing out o f a tvain window at the endless line of telegvaph poles whipping by, and wejind that pavt of what we aye looking at is OUT own ve3ectioa.

This chapter explores the journey couples under- take when they choose to enter therapy. Entering therapy is not easy, especially for distressed couples whose relationships are characterized by varying levels of outrage toward one another. Confronting the myriad problems associated with attention def- icit and hyperactivity disorder (ADHD) in a rela- tionship is, quite probably, the most difficult challenge facing a couple in therapy. Bringing couples face to face with their own issues, and chal-

Clinician’sGuideto Adult ADHD:
AssessmentandIntervention
ISBN0-12-287049-2 219

Anonymous

lenging them to acknowledge how those issues play out in the relationship, can be a very unmasking and unnerving process.

The symptoms and behaviors associated with ADHD influence relationships in varying ways. A partner suffering with chronic depression will strain the relationship differently than a partner whose ADHD is confined largely to forgetfulness. It is essential that the therapist working with the couple understands the precise nature of the

220

symptoms encroaching on the relationship (Chris- tensen & Heavey, 1999).Depression, which is often a condition coexisting with A D H D in adulthood, can create a circular interaction pattern whereby the depression serves to increase martial distress, while the marital distress exacerbates the depres- sion (Gotlib & Beach, 1995). Knowing how the couple interprets the strength of the symptoms can indicate the depth of marital dissatisfaction.

This chapter will discuss two methodologies that have shown a great deal of promise in helping couples move farther down the relationship path and closer to embracing their own reflection in what can both hurt and heal the relationship. It will focus on the couple working in tandem to reduce marital stress and improve the quality of their re- spective lives. Since ADHD can often have nega- tive effects on the marital relationship, working with the couple, irrespective of individual therapy, has the potential of liberating the couple from long- standing disappointment and entrenched negative behaviors (Jacobson & Addis, 1993).

Please note that the names used in the course of the chapter, especially the anecdotal examples of therapeutic interaction, are fictitious and are not intended to represent any specific person in ther- apy. Additionally, although there are many models of relationships in existence, the author will refer to individuals in a relationship as “spouses” for sim- plicity’s sake in this chapter.

OVERVIEW

In the field of maritalkouples therapy and coun- seling, relationships that can be objectively quali- fied as “successful” or “nurturing” have certain distinct and lasting characteristics. Primarily, the individuals in the relationship tend to:

0 Be more separate as persons (less dependent on what the significant other says or does in order to feel prized and confident about self)

0 Exhibit high levels of self-esteem and self-worth

Patrick J. Kilcarr

0 Be more tolerant of one another’s personal foibles and regressive behavior

0 Have a clear communication ritual about topics that may be emotionally sensitive or difficult to discuss

0 Treat formerly “charged” issues with humor 0 Have more realistic expectations of the

relationship and one another
0 Express deeper levels of affection and be able

to discuss issues of sex openly
0 Display less hostility toward one another
0 Be more accepting of the natural ebb and flow

of intimate relationships
0 Not be deeply disappointed that they are not

passionately “in love” every waking minute (Markman, 1979).

These characteristics are important to consider when entering into a therapeutic relationship with couples who often initially present from the opposite place-i.e., an overarching sense of personal and relational despair, mixed with very little trust and even lessmutual nurturance (Novotni, 1999).Symp- toms attending the presence of ADHD in a partner- ship can “suck the air” right out of even the most promising relationship. The following will guide the reader in moving couples away from an emotional abyss and closer to a fulfilling and loving relation- ship.

Although there are many “different roads to Rome,” the two therapeutic approaches discussed here seem to be particularly helpful in diminishing the stored-up anger while simultaneously offering the couple a more reasoned and loving way to manage ADHD issues specifically and relationship issues in general. The chapter will also highlight the use of specificcommunication strategies to diminish anger. Finally, issues specific to ADHD and sub- stance abuse will be discussed. Active substance abuse (like depression)-not uncommon for those attempting to manage ADHD-related symptoms in their lives-must be proactively addressed early in the therapeutic process. It is something the therapist mustaskaboutdirectly.Thefrequency,intensity,and

12. Making Marriages Work for individuals with ADHD

221

should “just relax and take things in stride,” the more over-the-top anger develops and is directed toward the person with ADHD.

In essence, by the time a couple “darkens a therapist’s doorstep,” at least one of the spouses has “one foot out the door.” Both are exhausted, burned out, and, in some respects, feeling hopeless. As a husband reported to the author recently, “I feel like the pilot of a 747 making one last-ditch effort before the plane goes down.”

As a therapist, instilling hope is critical. How- ever, if either spouse is not open or committed to exploring different strategies in the relationship, instilling hope will be of little consequence (Chris- tensen & Heavey, 1999).

It has been the experience of the author that, when working with couples where ADHD is the principal culprit, an engaging, interactive, and pro- active methodology is most advantageous. While insight-oriented therapy can help individual’s understand why certain patterns continue to unfold in the relationship, immediately offering the couple tools to interrupt the negative patterns is critical. Seeing a couple for the first time amplifies this point, as in the following dialog.

T So, what brings you both here today?
w Well,weheardalotabouttheworkyoudowith people who have ADD. My husband has it; he is honest about it. We tried a therapist before who just sort of nodded as we spoke, wrote stuff

down, and occasionally stated the obvious.

T Was it helpful, talking to the therapist?
w It was helpful to talk-getting things out in the open-but when our time was up, we just went home without any sense of real direction or

what to do.

T So there was more you were looking for. What about for you, John? Do you feel similar to your wife?

H I think it was important, but most of the time it was my wife ragging on me about crap I hear all the time anyway.

duration of substance use must be established. Even if both spouses enter therapy willingly and with high hopes, the abusiveuse ofsubstances byeither or both will serveto effectivelyundermine any realmovement toward change or personal growth. Overlooking this, or downplaying its importance, wil undermine a positive therapeutic outcome (Jacob, 1988).

FOUNDATIONS: SETTING THE INITIAL STAGES OF THERAPY

By and large, in cases where ADHD-related symptoms play a significant divisive role in the rela- tionship, couples seeking therapeutic intervention have already tried countless strategies and methods to “change” one another’s negative behavior and attitude (Markman, Floyd, Stanley, & Clements, 1993). Each demands the other spouse change, and will not yield or budge until some type of impact is evidenced. Couples initially enter therapy with the intention to do everything possible to change the other person (Olson, 1976). Of course, this serves only to tighten the emotional “airlock” even further for each spouse when acting within the relationship.

When seeking therapy, couples are often lacking in three specific areas:

1. Their arsenal of prevention skills are depleted 2. Their abilities to communicate without resorting to the expression of derailing

emotion(s), particularly anger, are

compromised.
3. They promote the perspective that their

spouses are “acting” in a particular and deliberate way to upset them-an undercurrent similar to that felt by parents about a child with ADHD (Kelly & Luquet,

1998).

The non-ADHD spouse is infuriated with the constant disjointedness of the other, while the spouse with ADHD feels he or she can do nothing right. The more the afflicted spouse tries to assure the other that he or she is trying and that the other

222

T: It felt like more of the same. H: Definitely.

T: How would you like to see things happening here?

H: Be more positive, build on the good stuff, learn ways to communicate better. Like that.

w: I like us to be able to communicate, but he has to start listening to me and taking responsi- bility for what he does-

H: See, it’s all about me.

T: Are you both willing to see the relationship and one another differently-not only try, but learn, new ways of dealing with each other? I mean, practice these new things be- tween sessions?

H&W Yes.

T: ADHD has been part of this relationship from the beginning. Parts of ADHD that used to be fun and enjoyable may no longer be; possibly, the symptoms also may have strengthened over time and become an irritant. What I gather is you want things to be different, or you would not have tried yet another therapist. Making changes means working together-hearing, re- sponding, and consistently acting differently toward one another. ADHD is not going to go away. It requires managing the symptoms and working together-and taking responsibil- ity for individual issues.

T: Yes, and vice versa. As you shift your attitude and perspective, he will also shift. Changing on your own, individually, will change the rela- tionship. Let’s explore some ways to accom- plish this.

Providing a couple with the opportunity to vent and tell their story is essential. It is the first step in providing them with a critically needed arsenal of solid skills, information about ADHD, and strat- egies to reshape their relationship. To be offered

Patrick J. Kilcarr

W Yes, but I am not the one with the problem. If he changes, I know I’ll change.

Acknowledge the issues for which the couple has come to you.
Probe their understanding of ADHD-related issues.

Define what is working in their relationship. Challenge them on what has not been working for them (i.e., more of the same behavior). Assist them in mutually defining what they want to have in their relationship (goals). Instill in them the fact that, for change to occur, it must start with each spouse individually.

TWO THERAPEUTIC APPROACHES

The following two models used in working with couples in varying degrees of distress were chosen for the expediency with which relational change can occur. Contextual therapy and behavioral marital therapy focus on presenting the inter- actional sequences between spouses that result in tension, negative intent, and an overall lack of enjoyment. Very little attention is paid to the past history of either spouse individually; however, both therapies are interested in what has transpired in the past when the couple has tried to “fix” what they perceived to be the problem(s). Embedded in these attempts are clues that can assist the couple in realizing and actualizing a positive relationship change (Weiss, 1978).

Spouses generally continue to interact in estab- lished and entrenched behavior rituals, despite the apparent fact that the behavior is not creating a desired change in their spouses (Knudson, Gurman, & Knishern, 1980). Both therapies work to uncover

strategies and skills by a therapist signals hope to the couple (Halverstadt, 1998; Satir, 1964). It also offers the opportunity to quell some of the seething resentment. The following provides a template to consider during the initial interview with the couple.

Initial Stages of

Therapy

12. Making Marriages Work for individuals with ADHD

223

I heard you both mention that Donna has ADHD. I am wondering what role this plays in your cycle of fighting and then distancing from one another?

I am not sure what you mean by what role it plays. She takes medication, so it is basically controlled. ADD is not the cause of our prob- lems. It’s the fact that the house looks like a mess and I am tired of constantly being the one to try keeping things halfway neat.

What I mean is precisely what you just men- tioned. Have you two ever had anyone actually talk to you about how ADHD can affect your relationship? One of the hallmarks of A D H D is an inability to be organized. It feels like life is one big chaotic mess. It’s not that the person doesn’t try to “get with it and get things done”; in many ways, it’s that they need a specific type of support to help stay on task. I would like to talk a bit more about the characteristics of ADHD. Then we can talk about a way that Donna can get a different type of support through you, while you in turn feel the house is more organized and less messy.

these repetitive patterns and replace them with posi- tive interactional patterns that stem from the goals that embody what they both want in the relation- ship. Both therapeutic approaches take the view that we humans are largely products of our conditioning; therefore, they seek to change the stimuli in order to, by necessity, change the behavior. Thus, this change occurs when spouses consistently replace their trad- itional problematic communication-behavior pat- terns with mutually satisfying exchanges in the varied situations they face (Boszormenyi-Nagy, 1978).

Contextual Therapy

The practice of contextual therapy is based upon the understanding that certain fundamental prin- ciples guide the stability (or instability) of an intim- ate relationship. Boszormeni-Nagy (1978) notes that both spouses must fully understand the nature of a disorder that affects the functional health of the relationship. In the present context, both spouses must understand the impact of adult ADHD-on the person trying to manage ADHD internally and on his or her spouse. A “reciprocity” of understanding must first exist so that each spouse can fully appreciate how A D H D affects them both. This can exist only if the facts surround- ing the disorder-its emotional, psychological, oc- cupational, spiritual, and relational aspects-are known and accepted by both spouses. This is an attempt to offer explanations for certain behaviors, rather than to generate excusesfor either spouse. It cannot be overstated that it is also equally critical to understand the impact of ADHD-related symp- toms on the non-ADHD spouse. As one spouse once said, “I don’t have ADHD, but the result of her ADHD makes me feel like I do sometimes. Everything just feels out of whack.”

In the course of the first therapy appointment, once both partners have had a chance to discuss the chief complaints, a contextual therapist may ask such things as the following.

T H

Once the facts of adult ADHD are uncovered and discussed by the couple in the therapeutic environment, the therapist and the couple can begin to explore the influence of the disorder on each spouse. In essence, the couple will unearth the meaning that has been attached to behaviors of importance (Boszomenyi-Nagy, 1978). For in- stance, a husband forgets to stop at the store and pick up bread on the way home. Since this has happened before in many different circumstances, his wife interprets his forgetfulness (an attribute of ADHD) as a sign of profound disrespect and irre- sponsibility. The action (forgetting to get the bread) is thus interpreted by the wife as a signature of disloyalty; the behavior is thereby transformed into a focus of major marital stress.

The following is an example of how meaning is attached to elements of importance by a spouse and how that meaning can keep a spouse with ADHD

224

stuck in a repetitive and unfulfilling cycle of disap- proval and tension.

W It never fails. I ask him to do something… something as simple as picking up a loaf of bread, and he comes home all smiles and looks at me as if I should be all happy to see him. He is clueless. I ask where the bread is, and he just stares at me with this vacant look. He doesn’t even say “sorry” or anything.

T: You interpret this as a lack of caring? W Anybody would.

T: What have you done in the past to address this issue?

W ItellhimIaskverylittleofhim.AllIneedisa loaf of bread, or the thousands of other small, simple things I have asked for and have never gotten.

T: Are there times where he follows through and does what you ask?

W N o t often enough.

T: Is it nice when he does follow through for you? W It’s like…it’s about time, you know? This is

what you are supposed to do.

T: Taylor, how often are you in the doghouse? H: When am I not in the doghouse? I can’t do anything to please her. When I do [follow through], she’s ticked because I should be doing it all the time. It really is damned if I

do and damned if I don’t.

T: What do you do then, when you feel continu- ously scolded?

H: That’s it! I feel scolded like a bad dog. What do you do when you can’t do anything right to please someone? I deal with it by not dealing with it. I turn away and get away from her as quickly as possible. Of course, she follows me, slinging barbs and calling me an idiot. Like she can really make me feel worse than I do! I know I forget stuff and act too much like one of the kids, or don’t remember things she men-

Patrick J. Kilcarr

tions to me, like things we are going to do. It’s very hard to be me sometimes.

W It’s not too hard to remember basic things. You remember what you have to do at work. But when I ask things, literally,forget about it! It means you don’t care.

This vicious cycle keeps this couple locked in an a very suffocating parent/child relationship. They have internalized, personalized, and attached nega- tive intent to the behavior stemming from ADHD. The wife globalizes her husband’s forgetfulness, while he fuels her anger by refusing to acknowledge the inappropriateness of his forgetfulness.

It is also possible for a non-ADHD spouse to feel that the spouse with ADHD is using those symptoms to align against her or him (Bowen, 1978). If the afflicted spouse either fails to take responsibility for ADHD behaviors or uses them as an excuse, the non-ADHD spouse can feel sub- sumed by a feeling of powerlessness. This can result in a mutually destructive interaction sequence, resulting in severe power struggles.

When a couple gets to the point where the rela- tionship is characterized by seething anger with occasional respites (as demonstrated by the previ- ous example), the therapist’s responsibility is to invite the couple to consider the concepts of rela- tional ethics or equitable fairness (Boszormenyi- Nagy, 1978; Boszormenyi-Nagy & Spark, 1976). These concepts measure the degree to which the couple is interested in redirecting their established negative communication and interactional pat- terns. The first step in beginning the process of change involves having the couple define what it would mean to have an “equitable” relationship.

Both spouses are entitled to have their interests and welfare considered. This process takes these values into account by defining what it would take for the couple to achieve mutual respect and trust- worthiness. What would each need to see from the other person to risk shifting his or her own perspec- tive?What would each be willing to do differently in order to achieve the results they both want?

12. Making Marriages Work for individuals with ADHD

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willing to do to begin creating the type of rela- tionship you want. Up until now, Anne, you have been waiting for Taylor to change. And Taylor, you have been waiting for Anne to be more understanding. All the while, you are both continuing to treat each other with disrespect and anger. Let’s begin defining what you could do to have the type of relationship you de- scribed.

Prior to this conversation, the couple relentlessly engaged in a perilous dance, undermining the basic marital trust and perpetuating “relational stagna- tion” (Bowen, 1978). This pattern of interaction ignores the essential premise that basic loyalty toward one another is reinforced when fairness binds the relationship. Unlike children, who will keep trying relentlessly until their trust in their parent is utterly depleted, spouses will not instinct- ively show the same resiliency toward one another. Even if a couple locked in this pattern chooses (or, more accurately, resigns) to stay together for moral, financial, or other reasons, the level of loy- alty to the relationship is profoundly weak so long as the underlying problems remain unaddressed (Jacob, 1988;Satir, 1964).

Murray Bowen (1978) noted that the process of individuation, or differentiation of self, occurs in a context of being responsible to and for others. To use a Biblical example, when Moses related the covenant between God and the Hebrews in the form of the Ten Commandments, he did not edi- torialize what he was directed to convey by saying “I will follow this commandment only if I like it” or “only if it servesmy best interest.” In its essence, the Ten Commandments embody the ultimate de- scription of human responsibility. It invites every- one to “do unto others as you would have them do unto you.” Each spouse’s owning responsibility for his or her own behavior-regardless of their origins or of the forces that sometimes influence them-is necessary for lasting therapeutic change to occur.

If we want loyalty from those around us-especially our spouses-then we must assume

Continuing the discussion with the previous couple will more accurately define this process.

T: All right, it is obvious you both are angry and hurt.

w: What does he have to be hurt about?I am not the one forgetting to do the things he asks. Maybe I should just forget to pick up the kids, or his clothes, or his mother when she calls.

T: When you get this angry and hurt, so angry you could just burst, how does it benefit the relationship?

w: I feel better. I don’t feel so controlled.

T: I understand how it makes you feel. However, I am interested in how it benefits the relation- ship.

H: It only makes us more distant. It doesn’t bene- fit anything.

T: Would you agree, Anne?
w: It doesn’t help us. But it does make me feel

better.

T: What would you like to have in your relation- ship? How would you like it to be?

w: I’ve said this a zillion times. Just listen to me, and remember something when asked by me!

T: Again, this is a bit tricky. However, I am asking how you would like the relationship to be rather than how you want to be treated.

H: I want us to be able to talk about difficult things without becoming angry or distant, for there to be enough respect to want to hear the other person and do whatever is possible to meet our needs. I want to laugh.

w: I want to be close. To rely on each other for support. To deal with anger or disappointment respectfully. Like Taylor said, to live with re- spect, really.

T: Part of our challenge, then, is to define what it wouldmeanforbothofyoutolivewithandtreat each other with respect. Defining the concept of respect is important. It begins with what are you

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responsibility for our behavior (Boszormenyi- Nagy, 1978; Kosten, Jalale, Seidl, & Kleber, 1987; Liberman, 1970; Markman, 1979). While we can share loyalty (for instance, loyalties we owe to our spouse, to our children, and/or to our coworkers), we cannot split loyalty. To illustrate using our example, the wife was splitting her loyalty by vacil- lating between her roles as spouse and as parent. This type of split creates divisiveness and confu- sion; in turn, this further fuels the firestorm of anger on both spouses’ parts. The therapist in our example began to lead the couple on a journey toward relational integrity through self-motiv- ation. This entails work by each spouse to redefine relational commitments and realign the balance of fairness (Jacobson & Margolin, 1979).

In order to foster such realignment, a therapist may ask probing questions, such as, “What happened after that event?” “How did you see her treat you?” “How would your spouse have described what made you so upset?” “How would you have wanted it to happen differently?” The goal of these exchanges is to get the couple to shift their intentions so that they can create an environment where they more deeply understand one another. Of course, this takes a willingness to abandon established patterns and to finding the motivation to resist allowing these “old” patterns to continue dominating their reac- tions and interactions (Stierlin, 1976).

Theprimaryshift inintentionsinvolvesembracing a willingness to “imagine” what the other spouse may feel or experience during specific negative situ- ations (grasping the partner’s interpretations of events). An example would be for the husband in our previous example to describe what it must have beenlikeforhiswifetorelyonhimandaskhimtodo something and then for him to fail to do it. The flip sidehasthewifedescribethefeelingofbeingberated, even emasculated, when he forgets.

The following is example provided by a different couple.

T: All right Ben, Karen is describing what it is like for her to live with the uncertainty of not know-

Patrick J. Kilcarr

ing if you will stay in this current job or get restless and leave for something on the spur of the moment. She says you are beginning to talk in ways that usually indicate that you are about to leave your job. Can you put yourself in Karen’s shoes and describe what it would be like to live, as Karen puts it, “on the edge of an abyss?”

H It would suck, but I am not going to do any- thing stupid.

T (gently leaning in) Slow down. It is very import- ant that you describe what it would be like to be in that position. How would it feel? What would it be like?

H It would make me very nervous. ..not knowing if there would be enough money to pay the bills, maybe having to move the kids away from their friends. My father was in the service, so I know what that felt like, which was bad. You know, a job is like the foundation of a house. If the foundation is weak, the structure is in trouble. And changing jobs without talking to me about it first would make me upset. I have a right to know, especially since I am her husband. It’s not a good feeling.

T Knowing this, how can you include Karen in the decision-making process and take her feel- ings into account?

Along with the shift in intentions is a description of intentionality. This involves the wife’s under- standing and accepting that her husband does not intentionally neglect her input or make snapjudg- ments despite her fears. His impulsive job changes and maneuvering are functions of his ADHD. His corresponding responsibility is to determine what skills or strategies he needs to employ to be less impulsive and to be more accommodating and in- clusive of his wife (Jacobson & Margolin, 1979).

Likewise, his wife does not initially intend to get angry and belittle him; rather, her frustration and inability to understand his behavior usher forth intense anger and hurt, often resulting in extreme

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apist’s office (Gotlib & Heavey, 1999). This may be completely different than the goal they originally stated. The therapist may say, “So, this past week seemed like more of the same. Can you describe precisely what you experienced as not working? Once we determine this, let’s revisit the goals you agreed upon and see how they need to be changed so you can experience success.”

The foundation of contextual therapy is the re- lational and interactional change that occurs when the couple chooses to replace disruptive communi- cation patterns with healthy interactional strat- egies, thus changing the context within which the relationship exists. These strategies are developed during the therapy sessions and are practiced be- tween sessions.

Here is a summary of how contextual therapy with couples should work.

The Use of Contextual Therapy with Couples

0 Educate both spouses on the facts regarding the impact of ADHD (on self and the relationship).

0 Explore the meaning each attaches to the other’s behavior. What type of behavior does this meaning ignite?

0 Identify the real or perceived power alignments against either spouse.

0 Define the concept of relational ethics, where both are entitled to have their interests and welfare considered.

0 Illustrate that relationship change emerges from clear and agreed-on goals established by the couple.

0 Continually refine the goals based on between- therapy behavior and interaction sequences.

Behavioral MaritaI Therapy

In many ways, behavioral marital therapy is an outgrowth of social learning theory (Mahoney, 1974), which attempts to describe the pervasive effects of social influence on the development of

put-down behavior. He must realize that her out- bursts are reactions to the situations and not “value judgments” as to his worth. For her part, she must determine what skills or strategies she needs to acquire in order to manage her annoyance in ways that are not damaging to her husband and by extension to the relationship (Stierlin, 1976).

Establishing new patterns of behavior and inter- action requires that the therapist track the move- ment of the couple toward their stated goals of change in their relationship. Goal-setting outlines, in very detailed language, set out where the couple wants to be and what they are willing to do differ- ently in order to get there (Sager, 1976;Margolin & Weiss, 1978). If they are struggling, the therapist can ask, “I wonder what more you can do at this point. You are willing to hear each other differ- ently, yet things at home seem very similar to when you came in. What are you not doing enough 00’’

Even if the couple reports failed attempts (such as “I try, but it doesn’t seem to help”), the therapist can engage with follow-up questioning that will reveal the context (the backdrop to what the couple is and is not doing), for example, “What do you try, and how would you know if it was working?” (Haley, 1976). It is always essential to define the context within which the couple is attempting to make changes. The most important context within which the couple interacts surrounds their stated goals for change (Jacobson, 1977).

Movement by one spouse will necessarily influ- ence the movement of the other (Halverstadt, 1998). True “neutrality” does not exist in any rela- tionship, particularly a strained one. Therefore, a positive movement by one spouse will beget some type of shift in the other; the same is certainly true for negative behavior. The goal(s) they are working toward will provide the impetus for every instance of growth or regression (Knudson et al., 1980). If they say they have a particular goal yet are not working toward it between sessions, the therapist must develop a goal that is agreed upon and re- inforced by action beyond the confines of the ther-

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behavior in human beings, most specifically that of verbal and nonverbal communication (Gottman, Markman, & Notarius, 1977). Each spouse brings to a relationship his or her own personal reinforce- ment history and an emotional ledger detailing the cost and benefits of the spousal relationship. These include ideas of very specificbehaviors and interac- tions that are considered either positive or negative.

This discussion will strive to elucidate the behav- ioral ingredients embedded in a “successful” or “satisfactory” relationship. While that is defined differently for each individual (and therefore each couple), certain criteria seem to indicate the strength or health of a relationship. A relationship can be extremely gratifying to both partners during its initial stages, only to crumble when they must traverse its initial major conflict (Christensen & Heavey, 1999). The symptoms associated with ADHD can escalate this conflict in an unrelenting fashion (Kelly & Luquet, 1998).

From a behavioral perspective, “satisfaction” in a relationship is dependent on the rate of reinfor- cers (positive behaviors) received from the spouse. The frequency with which reinforcers are received will determine the rate of rewards the spouse is willing to return. ADHD lends itself to a dynamic wherein the spouse perceives very little consistent reward, thus becoming less willing to give in return. An individual’s reinforcement history and predilec- tions for certain reinforcers are not static or fixed. Rather, they are constantly modified by experi- ences in the relationship (Weiss, 1978).

These modifications are often based on the “rules” that exist in and govern the relationship. Haley (1976) noted that intimate relationships re- quire a complex division of roles, responsibilities, and obligations in order to function smoothly. This occurs only where considerable consensus between the spouses exists regarding which behaviors are appropriate and which inappropriate in particular situations.

By their very nature, ADHD-related behaviors serve to undermine the prospect of a relied-on div- ision of roles and responsibilities within the rela-

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tionship. Normative reinforcing behavior is frequently overshadowed by the inconsistent and negative secondary effects of ADHD. If the rela- tionship is not governed by predictable rules, mu- tually rewarding behaviors decrease in frequency and intensity (Weiss, 1978).The degree of satisfac- tion that spouses experience in the relationship depends on how the couple relate to one another with respect to the specific needs of each. If these needs are not positively addressed, satisfaction and stability decline (Patterson, 1976). Jacobson and Anderson (1980) point out that there is some evi- dence that, as the expectation for rewarding behav- ior dwindles, distressed couples notice “selectively” and attend almost exclusively to negative behavior. The following describes the interaction between a couple and a behavioral marital therapist where both spouses suggest that the “costs” of the rela- tionship far exceed the “rewards.”

T Sheila, you mentioned you are extremely un- happy with your life right now. Have there been times in the relationship with Todd when you were more satisfied?

W After we got married, Todd would take me out to dinner after a long day at the office. He would surprise me with a rose or some type of gift-not expensive, just something to show how much he cared. He would call me during the day and chat. Basically, he was interested in me. He showed he cared by the small things. He did them consistently, though.

T And what changed?
W Work and his clients became more important

than me and the children. I guarantee his clients know he cares. He takes them to dinner, buys them wine during the holidays, has his secretary send out cards. The most attention I get is a “Hi, hon” when he comes home, when- ever that might be.

H What do you expect? You are nothing but a sourpuss constantly. I am tired of hearing what I am not doing for you. Yeah, I do work long

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Even if I did start doing these things again, she still would find something to be angry at me about.

I don’t know if that is true. I know that show- ing caring in ways that are positive for your wife will certainly change her attitude and feel- ings toward you. Would you agree?

Yes, I guess.

hours. I know at work where I stand and how the system works. I know when I do the right thing I will get praise-not “Oh, even though you did this, you forgot to do thus and SO.” Come on. No one in his right mind would subject himself to this!

This couple has conditioned one another to seek out and expect the worst in the relationship. As a result, positive moments are overlooked in an at- tempt to identify the negative behaviors that are at the center of their unrest. Unhappy couples tend to attempt to bring about behavior change and com- pliance through aversive control tactics-that is, by strategically presenting punishment and withhold- ing rewards.

As we will see, the therapist attempts to promote the notice of enhancing stability and satisfaction by linking current conflict antecedents in the couple’s interaction with undesirable relational outcomes.

T: You both mentioned very specific things that bother you in the relationship. Take a moment and describe for me what leads up to the con- flict and unrewarding interaction. Now Todd, when you hear Sheila describe what bothers her, what creates the problem situation? What d o you hear her saying?

H: I suppose that I don’t do anything right.

T: Sheila, is that accurate?
w: No. I said it [the problem] is not paying atten-

tion specifically to me. Like taking me out to a quiet, enjoyable dinner, bringing flowers occa- sionally, letting me know you still care.

H T

T: When these things don’t happen on occasion, what happens?

This same type of exploration was done with the wife. She realized, after “stepping into Todd’s shoes,” that she would summarily dismiss whatever he would say because she was angry and wanted to punish him or at least have him experience her frus- trations. This only served to make him even more recalcitrant in his responses toward her. Choosing to hear him out would more closely approximate the type of response she has been looking (longing) for.

Changing the previously negative antecedents leading to the relationship’s problems will have a positive influence on how the spouses begin to view the level of satisfaction that exists in the relation- ship. By increasing the reinforcement value for one another, a greater likelihood exists that those re- inforcing behaviors will be applied to other areas in the relationship (Jacobson, 1977).

Flow of Behavioral Therapy

Several aspects of behavioral marital therapy are important-the flow of the therapeutic process and enhancing positive regard within the relation- ship. Behavioral therapists working with couples generally follow a specific format to achieve a level of desired behavior change within the rela- tionship. The first part of the process entails spend- ing very little time on the presented problem(s). The early history of the relationship is explored so the couple can refocus their energies on earlier, happier moments, with the intention of elevating the feelings of positive regard within the relation- ship (Jacobson & Martin, 1976). The couple is asked to reflect on how they met and on what

w: I get upset and try to make him feel like I feel-unappreciated.

T: So Todd, what are the things leading up to your wife’s anger?

H Not showing I care.

T: Not showing you care in very specific and pre- dictable ways.

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characteristics were initially attractive about one another. Details involving the courtship are elicited in order to begin reshaping their perspective toward one another. This alone helps place their current problems in a different perspective.

Patrick J. Kilcarr

The second part of the process entails exploring
the types of problems each spouse experiences. As
noted earlier when discussing contextual therapy,
spouses enter therapy feeling victimized by the
other and believe that the therapist must work
aggressively to change their spouse. In practice,
then, the therapist spends quite a bit of time defin-
ing the exact nature of the problem(s). This in-
cludes identifying the antecedents inciting the
problem, the couple’s interaction with respect to
the problem, and the outcome as embodied in the two.

couple’s resolution of the problem (Robinson & Price, 1980).

In doing so, the therapist can instruct each spouse to keep a behavior log of the other, documenting when and what type of troubling behavior occurred between sessions. When documenting these behav- iors, the spouse is not to respond but rather just to write them down and bring the notes to the following session. The therapist takes these respective ac- counts and converts them into language that avoids assigning blame to either spouse. The reformulated information is delivered in an objective manner and as an expert opinion. This servesto expand the cou- ple’s perspective, which, hopefully, leads to a consid- eration of other behavior options. The therapist facilitates their acceptance of mutual accountability and responsibility for maintaining the current dis- tressed state of the relationship (Liberman, 1970). This is important, because distressed couples, by the time they enter therapy, often severely underutilize the repertoire of reinforcers they already have. An example of this follows.

T: Let’s explore the type of interaction between you two that creates such tension in the rela- tionship. Todd, could you give us examples of what happens between you and Sheila to create such difficulties?

W Yes. However, I get so frustrated because I have told him so many times it is ridiculous. He doesn’t respect me. If he did, he would try to take my feelings into account and stop doing it.

T So, you ask Todd specific things that he doesn’t remember to do, or he keeps doing the same things over and over. What are those things?

W I ask him to clean up his clothes, put away things he takes out, pick up something on the way home-these type of things. His refusal to do them shows he couldn’t care less.

T Is it true Todd? You don’t care?
H Of course I care. I just get distracted and start

thinking about other things and forget, pretty much. I wish I could remember more things.

W You seem to remember everything you need to at work. If you did at work what you do at home, you’d be fired.

H I keep very detailed schedules at work to re- member. It’s hard, but I do it. I don’t want to have to work that hard at home.

T What you are saying, though, is that you have a system at work that allows you to be success- ful. Is there anyone at work that helps remind you of certain things you must do?

H “There’s a lot. To be specific, it is when I do something that annoys Sheila and she just blows up and starts giving me grief about any- thing or everything I have ever done. She starts getting all upset and then I shut down. It’s either that or explode.

T I want to understand this. You do something to upset Sheila She gets annoyed and begins bringing in a lot of past behavior or hurts that were not resolved. This gets you mad and you withdraw. Is this accurate?

H Yeah.

T Sheila, does this sound fair to you? I sense that this is one of the major stress points for you

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pointment arise, the therapist has them actually sign a contract acknowledging they will follow the instructions (Sager, 1976).When couples do this, a fairly high rate of compliance and subsequent be- havior change follow (Markman, 1979).

It is also important to inform the couple that progress toward sustained relationship improve- ment may tend to occur in a more inconsistent, rather than linear, fashion. Reminding the couple of possible “relapses” to pretherapy behavior helps diminish feelings of failure. In fact, merely men- tioning the potential of a relapse can help ward it off (Haley, 1976).

Enhancing Positive Regard

There are several strategies the therapist can employ to enhance positive regard in the relation- ship, including contingency contracting and com- munication training.

ContingencyContract Weiss, Birchlerr, and Vin- cent, (1974) developed a tool called the contingency contract. This strategy is generally most effectively used by couples who find it very difficult to make any type of substantive change within the relationship without some level of assurance by their spouse that they will also shift their behavior. The contingency contract essentially states, “I will do this, if you will do that.” This quid-pro-quo relationship is most effective when both sign an agreement detailing the type of behaviors that each will demonstrate.

Eachsessionfollowsuponthesuccessfulcomple- tion of the contract. The contract should be equally costly (and beneficial) for both spouses. It should delineate what happens if someone does not follow through. Finally it should include how the couple should celebrate following the contract. Also, the exact nature of the contingency should be specified (that is, when, where, and how much of the behavior must occur in order to produce the partner’s “re- inforcer”). Lastly, the contingency contract must spell out how the exchange is to be reinstated in the event of a transgression by a spouse.

H: Yes, my secretary. She keeps my schedule and reminds me-and at times re-reminds me-of what I need to do.

T: H:

Can you describe how she asks you? It seems she asks in such a way that you respond and are successful.
She just writes me a note reminding me. Or, now that I am thinking of it, she uses gentle touches on my shoulder so I look at her, and then she reminds me.

One of the primary issues of having A D H D is the high level of distraction that can be very annoying for both the person with ADHD and significant others. Taking models that are successful in one place, like work, and using them in other places, like home, will certainly reduce the distraction and forgetfulness that ac- companies ADHD. I don’t believe you will have to work harder or be a slave to lists. You both can partner with one another to be more success- ful. How can your wife appropriately remind you in conjunction with strengthening your commitmenttofollowingthrough?Youalready seem to have a good formula for success. Once you begin working as a team, rather than aligning yourselves as adversaries, things will change significantly. Let’s describe exactly what this plan would look like.

The therapist taps into an existing positive rela- tionship in the husband’s life and suggests extrapo- lating this process to home and the relationship with his spouse. As in every other area of joint therapy, both spouses have to agree to work to- gether on shifting the relationship. Enhancing the spouses’ collaborative behavior involves obtaining their commitment to follow the therapist’s instruc- tions. The therapist informs the couple about what they can expect from each other if they follow this new formula. To demonstrate its practical viability, some role-playing, based on a recent incident, is initiated in the session. Once the couple has a clear sense of what to do when tension and disap-

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Communication Training A critical part of be- havioral marital therapy lies in training couples to utilize effective communication strategies (Jacobson & Addis, 1993). One of the primary reasons that couples seek therapy is that they have lost the art of communicating. Communication training tends to be change oriented rather than expression oriented (Weiss, 1978).Whereasmost approaches to commu- nication training focus on the reception and expres- sion of feelings, behavior therapy teaches couples how to communicate in order to facilitate the reso- lution of conflict. While the expression of feelings is important, the skills imparted to couples in therapy attempttotrainthemtosolvefutureconflictsbetter. This consists of four basic elements: rehearsal, feed- back and shaping, mirroring, and solution focus.

Rehearsal (PracticeMakes Perfect) As couples practice the new behaviors, they move closer to achieving mastery of the new interaction skills. Re- hearsal provides feedback to the therapist of the individual’s competency in enacting the new skill. Corrective feedback, along with successiveapproxi- mations toward the desired skill, moves the couple toward competency (Jacobson & Anderson, 1980).

Feedback and Shaping The couple’s practice attempts receive feedback from the therapist. Ther- apists tend to be descriptive rather then interpret- ive. The therapist should therefore focus on the functional aspects of the behavior (e.g., “Is it get- ting you what you want?”). Thus, the therapist will point out negative behaviors that occur in session: “Did you realize you just interrupted her? This is one of the key behaviors that bothers her.” The whole training process can be thought of as a type of “shaping,” because it endeavors to shape the couple’s behaviors to be more in line with what they want and expect (Patterson, 1976).

An essential element of shaping is being able to communicate individual needs accurately and maintain realistic perceptions and expectations of one another’s behavior (Weinstein & Block, 1998). Individuals with A D H D have difficulty

Patrick J. Kilcarr

slowing down their thought processes enough to actually hear what their spouse is saying. Their thoughts barge right by the important messages the spouses is trying to impart. They are busy thinking about a variety of things, none of which immediately register with what their spouse is trying to convey. Understanding this can give way to utilizing very specific strategies to focus the spouse in on what is being said.

Mirroring This author uses a modified version of a mirroring technique in order to focus couple communication while concomitantly identifying and reducing the faulty transmission or reception of information. This requires couples to look one another directly in the eyes, say what they need to say, and wait for the spouse to “mirror” back what they heard (or thought they heard). The following passage demonstrates this technique.

T Now I would like you both to try the mirroring technique with one another. I know it seems almost silly, having to parrot back what the other person is saying, but I think you will find it enlightening to learn what you have been missing in your conversations. Jim, you start with an issue you want to bring to Patty’s attention.

H Okay, Patty, I look forward to coming home at the end of the day. When I come home from work, I know you want me to begin pitching right in with the kids and talking with you about my day. But I need a little bit of time

just to shake off the workday before I can enter into the commotion of the family.

W You need more time to rest when you get home before I should ask you anything.

T Is that accurate, Jim? H N o t exactly.

T Can you repeat to Patty what you said? Patty, can you keep your eyes directly on Jim’s as he speaks? Jim, can you try to shorten it and be more concise?

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Here is a summary of the main points of behav- ioral marital therapy.

Essential Aspects of Behavioral Marital Therapy

Explore the early positive parts of the relationship in order to shift the focus from the negative.
Incorporate a clear and exhaustive understanding of the exact behaviors that are seen as problematic, along with a recognition of what each spouse does when these occur. Identify the solutions that have been tried to ameliorate the problem(s).
Role-play in the session. The couple brainstorms on solutions and receives corrective feedback to create mutual and lasting problem-solving strategies.
The couple signs a contract agreeing to follow specific between-session behavior outlined by both spouses.
Discuss the concept of behavioral reversal. Suggest that old behavior may creep back into the relationship, and identify methods whereby the couple can prepare for and prevent it.

SUPPLEMENTAL INTERACTION STRATEGIES

In addition to employing the techniques and strategies of contextual therapy and behavioral marital therapy, several communication strategies are available to couples that, if used consistently, can offer opportunities to create lasting change within their relationships. Where A D H D has been a principal organizing factor, a relationship experi- ences less emotional and physical satisfaction the longer it lasts. Affected couples define their relation- ships by what they lack rather than by what they possess. Years of arguing, unfulfilled expectations, andconsistentdisappointmenthaveleftthemfeeling barren in the relationship. The following sections describes two supplemental strategies that canmaxi-

H: I look forward to coming home at night. I need time to shake off the workday before totally engaging with you and the kids.

w: You look forward to coming home at night, and need time to shake off the workday before engaging with me and the children.

T: Was that accurate? H: Yes it was.

T: Did you feel heard by Patty?
H: Yes. And while it felt kind of artificial, I know

she heard me.

This type of mirroring continues for both part- ners around issues they want to resolve. They go back and forth, mirroring what they hear the other person saying. In the initial stages of this exercise, the spouses do not comment on what they hear. Later, they can respond to what is being mirrored (which itself is then also mirrored back). This is very effective in disrupting the common and nega- tive process whereby neither spouse actually hears what the other is saying. This retrains the couple to slow down, to hear exactly what the other person is saying, and to acknowledge that both heard it. This is followed by a reply that is in turn also mirrored.

Solution Focus Spouses learn to generate solu- tions through the process of brainstorming (Gold- fried & Davidson, 1971). Couples brainstorm by generating as many solutions to specific problems as possible, without regard to quality. The idea of thisexerciseistobeimaginativeandnottocensorthe other’s ideas. This is particularly helpful when the couple is stuck at the solution phase. Brainstorming can be liberating and can enhance the production of creative solutions. All solutions, however improb- able, are noted in writing by the therapist and dis- cussed in turn with the couple. Some suggestions are eliminated, the remaining suggestions are ranked, and the top solutions are chosen. A plan (the devel- opment of which requires mutuality and comprom- ise from each spouse) is devised, with a final agreement being written down and signed by all.

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mize the effectiveness of either (or both) general therapeutic approaches discussed earlier.

Caring Days

Olson (1976) describes a couple activity he termed caring days. It requires that each spouse list the behaviors he or she values in the other. The therapist spends time observing the compilation, in writing, of these specificbehaviors. The key is that these specific behaviors be able to occur at least once a day and preferably several times a day. Even highly dis- tressed couples can remember behaviors they enjoyed seeing in the past, such as, “I really used to like it when he would stop by the store on the way home and surprise me with dessert.” A brief sample list appears at the end of this discussion.

Creating this list is empowering for both spouses, because each now has a codified list of ways he or she can please and show appreciation for the other. Each spouse’s level of caring for the other is evidenced by the presence of these behav- iors. Marriage is monotonous and stale without the presence of these experiences, whereas the presence of these behaviors is a harbinger of increased com- mitment, stability, and satisfaction. As these be- haviors increase in frequency and intensity, each spouse’s motivation to be more giving and under- standing will likewise increase. Coupled with the skills of active listening, such as mirroring, in-ses- sion rehearsal of specific behaviors, and the use of corrective feedback, this approach can increase the expression of affection, reduce hostility, and move the couple significantly closer to their stated treat- ment goals for the relationship (Jacobson, 1977).

If both spouses agree to the “caring days” exer- cise,theymustagreetodemonstrateatleasttenofthe documented behaviors each day. The list they have createdisopen-ended,allowingfornewbehaviorsto be added on a regular basis. Each spouse is asked to demonstrate these behaviors independent of those of theother.Thisallowseachspousetheopportunityto model for the other the depth of his or her caring and

Patrick J. Kilcarr

commitment. It is not tit for tat. Although the be- haviors are offered irrespective of the other partner, if done consistently, a natural reciprocity will be es- tablished. Therefore, one partner’s failure to display acts of caring cannot be used to justify the other’s failuretodoso.Thetherapistmakesitclearthateach person is committing to this exercise. While each may expect the other to forget or not follow through, the “caring days” exercisewill occur because of their commitment. This countermines the tendency for each to withhold positive behaviors until positives are received and helps to neutralize the expectation that the other person must change first.

Each spouse is asked to record the number and type of caring behaviors he or she has both given and received from the other. At the end of the day, the total indicates each partner’s level of commit- ment to the relationship. If one partner does not show the “caring days” behaviors or does so mod- estly, the therapist revisits the couples’ goals for therapy and works with the couple to determine where the difficulties reside.

Sample List for the “Caring Days” Exercise

Wife’s Request:

1. Greet me with a hug and a kiss when you come home from work.

2. Surprise me with flowers.
3. Talk with me at night for at least ten minutes. 4. Tell me I look attractive.
5. Please don’t demean my having ADD.
6. Touch me gently some time during the day.

Husband’s Request:

1. Offer to make me breakfast when you make yours.

2. Rub my back.
3. If you ask a question, give me a little time

before I answer.
4. Tell me you still care.
5. Forgive my roughhousing with the boys. 6. Laugh at least once a day when you would

rather scream.

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encouraged to read each other’s letter aloud. Each spouse is asked to remember a grudge they have not been able to let go of in the relationship. (Some approaches have the spouses initially choose a grudge they are harboring for someone other than their spouse. This lessens the initial emotional impact and prepares the couple for when they per- form this exercise with each other.) The therapist clearly lays out the two ground rules: (1) Each spouse must agree to follow the specific rules (set forth by the therapist) addressing the emotionally charged information that will arise during the exer- cise. (2) At the conclusion of the session, unre- solved negative feelings are not to be carried out of the therapy room. Both spouses must agree to these ground rules in advance (Bornstein & Born- stein, 1986).

When the spouses have identified their grudge, they are not to say what it is. Rather, each is to write a detailed letter to the other covering all aspects of the hurt. The hurt may be repetitive in nature, may have resulted from an isolated occur- rence, or may have developed over time. The letter is to be written in the first person: “It hurt me when you did [thus and so],” or “When [this] occurred, [this]is what it felt like.” Aspects to be included in the letter include the following.

Part I

1. Historical perspective: When didldoes this hurtful experience occur?

2. Precise description of behavior that was hurtful: What exactly happened to create the painful experience?

3. Whatweretheemotionalfeelingsassociated with the behavior or event?

4. How did your spouse handle the situation when helshe knew you were hurt?

5. What did you do with the feelings after the incident? How did you react?

Part I1

6. What do you think was going on in your partner’s life at the time?

Budging Grudges

Typically, distressed couples enter therapy har- boring a great deal of mistrust and past hurt with respect to their spouses. This is particularly true for those presenting with issues related to ADHD. As noted earlier, the consistent disappointment and frustration when one’s needs have not been under- stood or recognized can create enormousgrudges (as defined by current feelings based on past hurtful experiences). Grudges are frequently (but not uni- versally) founded upon the differing perspectives of each spouse. These differing perspectives or mean- ings (which often develop into incompatible and unexpressed expectations) continue to escalate into full-blown relational fissures and impasses.

Uncovering and addressing these grudges-to allow emotionally charged feelings currently blocking the growth of the relationship to be ex- posed in a safe and nonthreatening environment such as therapy-is critical. Doing so in an artful and healing manner can be quite a challenge. With- out a definit plan, unearthing grudges in therapy can lead to ongoing volcanic eruptions that serve only to widen the emotional gulf between spouses. Many strategies attempt to manage past hurts in a curative fashion.

The moment spouses feel hurt or threatened, they begin bringing in prior unresolved issues that are born out of being hurt. Let’s look at an example often heard in therapy: “So what if I don’t praise you every time you do something you are supposed to? Why don’t you really show me you care by having sex once in a while? Wow, wouldn’t that be remarkable!” One spouse’s request to be praised occasionally triggered the other spouse’s seething anger about the lack of demonstrated caring (as expressed in this situation by a failure to initiate physical intimacy). This is a grudge.

During the session, the therapist invites both spouses to take a piece of blank paper and prepare to write a letter. Although not specifically intended to be mailed when finished, the spouses will be

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Part I11

9. What did you need from your partner at that time that would have reduced the pain? What did you need to hear, see, or feel?

10. Describe what could have been different at that time. Rewrite the script of that experience in such a way as to have the outcome you wanted.

11. What could you have done differently at that time to make the situation less hurtful?

The therapist and couple should allow at least two hours for this exercise. After the couple finishes the narrative, the therapist inquires what the writing experience was like for each. Couples often report initially experiencing a lot of anger when reliving the experience, only to have it lessen as they honestly answer the other queries. Each is then asked to read aloud what the other spouse wrote. The writer can help interpret the writing when needed.

It is very powerful when each spouse begins reading the other spouse’s account of a painful incident, accompanied by ways it could have been handled differently. The spouse who is reading is not allowed to comment on what he or she is reading. This is the other spouse’s perspective, and the expression of this, uneditorialized, is what counts at that moment.

Once each spouse reads the other’s narrative, the two are to move close together, hold hands, and acknowledge that this experience clearly hurt their spouse. Each then recounts from memory the reasons it was painful. At the conclusion of this part, the therapist inquires whether the spouse who related the experience in writing felt that the spouse accurately captured the essence of what was hurtful. If not, the spouse is asked to fill in what was overlooked, which is then recounted by the other spouse as well.

Patrick J. Kilcarr

The narratives are then given back to the re- spective owners, and both are asked in turn to reread parts I and 11. After the spouses read these parts of their own narratives, each discusses pre- cisely what he or she wants out of the relationship from this point forward. They also describe in detail what they will respectively do to avoid the escalation of a future situation.

This exercise can be extremely liberating for both spouses. This exercise may have to be repeated, based on the level of emotional intensity involved. This exercise can also incorporate many of the contextual or behavioral marital therapy strategies previously discussed.

SUBSTANCE ABUSE IN THE RELATIONSHIP

Habitually abusing (or becoming addicted to) substances has a profound negative impact on a person’s personal relationships, emotional integrity and balance, and overall positive life force. The abuse of substances creates an atmosphere poison- ous to relationships, leaving the abuser and his or her spouse living as if on pins and needles. Al- though problems coping with ADHD may bring couples to therapy, substance abuse problems may also be present or may even be the primary prob- lem. The therapist must ask in the initial interview directly about the type, intensity, frequency, and duration of substance use (O’Farrell, 1993). If a substance abuse issue exists but without addressing it early in therapy as the primary concern, the couple will not be able to achieve the emotional closeness that is the hallmark of a healthy and balanced relationship (Kosten et al., 1987).

Alcohol’s Functions in the Marital Relationship

According to Jacob (1988), Excessive use of alcohol serves three primary functions within the marital relationship.

7. What do you think your partner was feeling when helshe knew you were hurt?

8. Do you think your partner felt bad at all about hurting you? If so, how could you tell?

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problems will surface. Oddly enough, the abuse provides predictable, albeit unhealthy, interaction patterns in an unstable environment.

Serves to Regulate Emotional Intimacy

The substance abuse alleviates the perceived need for emotional intimacy in the relationship, fostering an emotional gulf between the couple. Creating and maintaining intimacy are often diffi- cult issues for someone living with ADHD; when substance abuse is introduced, a lasting and im- penetrable barrier to developing an intimate rela- tionship is created. In this context, intimacy is much more broadly defined than as mere sexual activity; it entails being able to identify and share the plethora of feelings that occur on a daily basis.

Like depression, the presence (or absence) of substance abuse in the relationship needs to be accurately disclosed before genuine skill develop- ment and emotional closeness can occur. Substance abusers generally utilize immature defense mechan- isms (characteristic of adolescents) in response to an increase in the level of stress within the relation- ship. When ADHD is layered on top of this, the relationship is injected with a potentially lethal ingredient. Before all else, the substance abuse must be addressed. If it exists yet remains hidden within the therapeutic process, the therapist must make it clear that therapy will be ineffective. Re- moving the impediments to intimacy is critical, first and foremost of which is the abusive use of sub- stances.

It is also important for the therapist to ask specifically about violence within the relationship. According to Christensen & Heavey (1999), vio- lence is often an undisclosed factor in highly dis- tressed couples. It may occur as a function of or independent of alcohol use and depression. Due to the confusing feelings of shame surrounding spousal abuse, asking the couple directly can begin to uncover abusive behavior the abused spouse would usually not willingly volunteer.

Signals Stress and Strain

Drinking and/or drug use is an attempt to min- imize either internal or external sources of stress. The internal source may be the individual’s having to live with and manage the primary and secondary effects associated with ADHD (such as moodiness, disorganization, and/or forgetfulness). The exter- nal stress may be related to job uncertainty, marital discord, family unrest, or a combination thereof. Unwittingly, the abuse of substances adds to the level of family and marital stress and strain. The use adds ongoing unpredictability and emotional distance in the marital relationship.

This can begin to create what Beattie (1987) refers to as codependency. Codependency describes an interaction between a non-substance-abusing spouse and the abusing partner, whereby the actions of the nonabuser often keep the abuser locked in an abusive cycle. The nonabusing spouse ritualistically makes excuses for the abusing spouse by doing such things as calling work to tell them he or she has the flu when actually the abuser is hung over. A repetitive interaction sequence is initiated that allows the abuser to continue the abusive be- havior. The codependent spouse counterintuitively supports the abuse in an effort to hold things to- gether in the relationship and family. This often creates a role for the non abuser defined by an excessive level of caring and enabling (allowing the abuser to continue to use the substance without regard to personal responsibility). Breaking the cycle of co dependence is often a significant aspect of the marital therapy as well as the impetus for the substance abuser’s entering sobriety.

Attempts to Stabilize a Chaotic System

Paradoxically, the more tension that develops in the marital relationship due to the substance abuse, the more the abusing spouse seeks refuge in the abusive substance(s). The substance use can also function as a lightning rod for other marital prob- lems. If the abuse remediates, then the underlying

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Here are things to do when addressing substance abuse issues.

Addressing Issues of Substance Abuse

Ask the couple directly if either believes that alcohol or other drugs, depression or relationship violence is a problem in the relationship.

Be candid that therapy will not work if there is an existing and unaddressed substance abuse problem.
Ask each partner the frequency, intensity, and duration of one another’s drinking patterns. This provides a potentially more accurate picture of uselabuse.

Read body language for level of comfort or discomfort as issues of substance use are explored.
If between-therapy assignments continue to fail and the couple is at a loss to explain why, revisit the substance abuse issue. This is often a reason for assignment failure.

Deal directly with issues regarding codependency. The co dependent is often as dependent on his or her role as the abuser is on his or her substance.

ASSUMING INDlVlDUAL RESPONSIBILlTY

As with most things in life, the success of couples therapy depends largely on the degree to which each spouse assumes responsibility for his or her role, behavior, and attitude within the relationship. When ADHD exists in combination with another problems, such as violence, substance abuse, or depression, it is paramount that the spouse with these issues assume responsibility for addressing them outside the relationship.

An individual with A D H D who also experiences anger or rage andlor acts violently toward his or her spouse or others must seek out an anger man- agementlviolence reduction program. This pro- gram must comprehensively address the myriad

Patrick J. Kilcarr

issues influencing the anger as well as outline and implement effective and healthy management strat- egies for coping with the anger when it surfaces. The process that unfolds in an anger management1 violence reduction program can be further ex- plored between the couple in marital therapy. Any change requires making successive approxi- mations toward a specified goal. The spouse experi- encing the violent behavior must be clear about his or her personal goals in terms of mitigating the violent behaviors.

The same is true for dealing with issues of addic- tion andlor substance abuse. It is critical that the spouse with coexisting ADHD and addiction issues be involved in some type of outpatient or inpatient treatment program that specializesin dual diagno- sis (the ADHD and the addiction). An intensive program will provide the spouse with a variety of immediate strategies to address the addiction along with either suggesting or requiring that the spouse join Alcoholics Anonymous or Narcotics Anonym- ous. Anonymous programs are very effective in helping those suffering from addiction to move closer toward sobriety. The nonaddicted spouse will also be encouraged to attend Alanon, which is for spouses and family members of addicts. It helps them understand better the process of addic- tion or abuse and supports them in taking a stand not to enable inappropriate or ongoing uselabuse behaviors.

Depression also frequently needs the support of an individual therapist or physician. It is clear that depression is often most effectively controlled through the use of both medication and cognitive- behavioral therapy. The medication is intended to positively effect the malfunctioning neuro transmit- ter-serotonin-in the brain, while the cognitive- behavioral therapy will help develop and reinforce the use of strategies to assist in warding off depres- sive moments and encourage the individual to learn to reframe negative situations, resulting in a much less depressive impact. This also can be brought into the couples therapy in terms of what type of support would be helpful from the nondepressed spouse.

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for immediate utilization in any therapist’s prac- tice, regardless of theoretical orientation. They serve to decrease negative intent while simultan- eously offering the couple myriad opportunities to experience lasting success and satisfaction in their relationship.

REFERENCES

Bandura, A. (1974). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.

Beattie, M. (1987). Co-dependent no more. Center City, MN: Hazelden Educational Materials.

Bornstein,F.,&Bornstein,M.(1986).Maritaltherapy:A behav- ioral-communication approach. New York: Pergamon Press.

Boszormenyi-Nagy, I. (1978). Behavior change through family change. In A. Bruton (Ed.), What makes behavior change possible? New York: Brunner/Mazel.

Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson.

Christensen, A,, & Heavey, C. (1999). Interventions for couples. Annual Review OfPsychology, 50, 169-197.

Goldfried,M.,&Davidson,G.(1971).Clinicalbehavior therapy. New York: Holt, Rinehart & Winston.

Gotlib, H., & Beach, S. (1995). A marital/family discord model of depression: Implications of therapeutic intervention. In N . Jacobson & A. Gurman (Eds.), Clinical handbook of couple therapy. New York: Guilford Press.

Gottman, J., Markman, H., & Notarius, C. (1977).A sequential analysis of verbal and nonverbal behavior. Journal of Mar- riage and the Family, 39, 461-477.

Haley, J. (1976). Problem solving therapy. San Francisco: Jossey- Bass.

Halverstadt, J (1998). A.D.D. & romance: Finding fulfillment in love, sex, & relationships. Dallas: Taylor.

Jacob, T. (1988). Alcoholic spouse interaction as a function of alcoholism subtype and alcohol consumption. Journal of Abnormal Psychology, 97,231-237.

Jacobson, N. (1977). Training couples to solve their marital problems: A behavioral approach to relationship discord. Part 11: Intervention strategies. International Journal of Family Counseling,5(2),20-28.

Jacobson, N., & Addis, M. (1993). Research on couples and couple therapy: What do we know. Journal of Consulting Clinical Psychology, 61, 85-93.

Jacobson, N., & Anderson, E. (1980). The effects of behavior rehearsal and feedback on the acquisition of problem solving skills in distressed and non-distressed couples. Behavior Re- search and Therapy, 18, 25-36.

This chapter has focused on specific methods proven to be clinically effective in treating dis- tressed couples where ADHD is one of the primary presenting problems. Contextual therapy and be- havioral marital therapy help couples develop spe- cific skills and strategies to successfully navigate terrain previously thought too hostile to inhabit. Aspects of these two approaches include guiding couples through understanding the factors associ- ated with ADHD, discussing the potential impact of living with the attending symptoms, mapping out goals indicating relationship success, and assisting couples to define their relationship anew.

In addition, two supplemental techniques were described for couples who register high on the negative relationship barometer. One reintroduces the couple to the more tender “caring days” in their relationship, while the other addresses standing grudges. The chapter concluded with a discussion of the reasons to rule out the presence of substance abuse, depression, and violence in the relationship. Substance abuse, depression (as well as other dis- orders), and violence can effectively and efficiently foreclose any option for the couple to achieve emo- tional stability and intimacy. These must be dealt with separate from those problems that arise in relationships coping with an ADHD spouse. It is recommended that individuals presenting with cooccurring conditions commit to some type of intensive therapeutic process aimed at extinguish- ing the other problem(s) existing along with ADHD. While couples therapy is very effective in dealing with issues specific to ADHD that is both diagnosed and being treated, it is not appropriate to rely solely on couples therapy to address individ- ual issues that have a profound negative impact on the relationship.

The effectiveness of the skills and strategies de- scribed in this chapter are often brought to life through interactional sequences between the couple and their therapist. These techniques allow

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Jacobson, N., & Margolin, G. (1979). Martial therapy: Strat- egies based on social learning behavior exchange principles. New York: Brunner/Mazel.

Jacobson, N., & Martin, B. (1976). Behavioral marriage ther- apy: Current status. Psychological Bulletin, 83, 540-566. Knudson, R., Gurman, A,, & Knishern, D. (1980). Behavioral

marriage therapy: A treatment in transition. In C. M. Franks & G. T. Wilson (Eds.), Annual review of behavior therapy,

Vol. 7. New York: Brunner/Mazel. Kosten,B.,Jalale,J.,Seidl,H.,&Kleber,H.(1987).Relationship

of martial structure and interaction to opiate abuse relapse.

American Journal ofDrug and Alcohol Abuse, 13,387-399. Liberman, R. (1970). Behavioral approaches to family and couple therapy. American Journal of Orthopsychiatry, 40,

106-118.
Mahoney, M . (1974). Cognition and behavior modijication. Cam-

bridge, MA: Ballinger.
Margolin. G., & Weiss, R. (1978).A comparative evaluation of

therapeutic components associated behavioral marital treat- ment. Journal of Consulting and Clinical Psychology, 47,

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Markman, H. (1979). Application of a behavioral model of

marriage in predicting relationship satisfaction of couples planning marriage. Journal of Consulting and Clinical Psych- ology,47,743-749.

Markman, H., Floyd, F., Stanley, S., & Clements, M. (1993). Preventing marital distress through communication and con- flict management training. Journal of Consulting Clinical Psychology, 13, 29-43.

Novotni, M. (1999). What does everybody else know that Idon’t? Social skills helpfor adults with attention de$cit hyperactivity

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disorder-A reader-friendly guide. Plantation, FL: Specialty

Press.
O’Farrell, T. (1993). Treating alcohol problems: Marital and

family interventions. New York: Guilford Press.
Olson, D . (1976). An operant interpersonal program for couples. In D. Olson (Ed.), Treating relationships. Lake

Mills, IA: Graphic.
Patterson, G . (1976). Some procedures for assessing changes in

marital interaction patterns. Oregon Research Institute Bul-

letin, 16(7).
Robinson, E., & Price, M. (1980).Pleasurable behavior in mari-

tal interaction: An observational study. Journal of Consult-

ing and Clinical Psychology, 48, 117-118.
Sager, C. (1976). Marriage contracts and couple therapy. New

York: Brunner/Mazel.
Satir, V. (1964). Conjointfamily therapy. Palo Alto, CA: Science

and Behavior Books.
Stierlin, H. (1976). The dynamics of owning and disowning:

Psychoanalytic and family perspectives. Family Process, 15,

277-288.
Weinstein, R., & Block, M. (1998). ADHD and relationships.

Attention Magazine, 5(3), 4 4 4 7 .
Weiss, R. (1978). The conceptualization of marriage and mar-

riage disorders from a behavioral perspective. In T. J. Pao- lino, Jr., & B. S. McCrady (Eds.), Marriage and marital therapy: Psychoanalytic, behavioral, and systems theory per- spective. New York: Brunner/Mazel.

Weiss,R.,Birchler,G.,&Vincent, J.(1974).Contractualmodels for negotiation training in marital dyads. Journal of Mar- riage and The Family, 36, 321-331.

INTRODUCTION

A D H D dramatically alters family life and tre- mendously complicates the job of parenting. People who live in a family with one or more parents with ADHD and perhaps one or more children with ADHDexperiencefundamentaldifferencesintheir daily living that other families do not experience, especially when the combined type of A D H D is involved. There is more tension and arguing. Sib- ling rivalry can be intense and unending, and the parental response to the fighting often makes the situation worse. There is constant noise. Dinner- time is not fun, and eating out is nearly impossible. Marital conflict is seriously aggravated, and divorce and separation occur more frequently than in the rest of the population. Vacations, instead of being the carefree and fun events parents hope for, become unhappy experiences where family mem- bers feel that all they do is switch from one prison (the car) to another (the motel room).

This is no way for parents or children to live, but there are millions of families that live this way day in and day out. Statistics about ADHD tell us that when there is a parent with ADHD, it is more than

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likely that there will be one or more children with ADHD. The reverse is also true: When there are children with ADHD, more than likely one or both parents will also have ADHD. This combination of parents with ADHD and children with ADHD intensifies and multiplies the effects of ADHD- related problems.

The good news is that, according to current research, there are therapeutic strategies that work in aiding parents to reduce family stress. Marital counseling can aid couples who are having trouble getting along (Gottman & Silver, 1999). Medication has been shown to be useful in many ways for both adults and children with ADHD (MTA Cooperative Group, 1999; Paterson, Doug- las, Hallmayer, Hagan, & Krupenia, 1999). Parent training can help moms and dads intervene more effectively with their children, enjoy their young- sters, and reduce the possibilities for child abuse (MTA Cooperative Group, 1999). Finally, cogni- tive therapy can help some individuals get “back to reality” and lessen emotional turmoil by thinking more clearly (Beck, 1995).

Generally speaking, there is probably not a more motivated group of therapeutic subjects in

13 Families and ADHD

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the world than the parents of young, preadolescent children. When these moms and dads have ADHD, however, the situation becomes complicated. Often the ADHD octopus is vicious, pervasive, and powerful enough to strangle attempts at workable solutions. Sensible-but often complex-proposals from bright, articulate, and sympathetic mental health professionals (from normal households) can sometimes be overwhelming for individuals and families with limited personal and economic resources. Therapies and tactics that require cogni- tive gymnastics and sustained effort under condi- tions of severe emotional overarousal often have limited success, especially when the implementers of strategies are adults with ADHD.

Two things are common in parents experiencing serious, constant emotional pain: (1) they feel hope- less,and(2)theydon’tthinkveryclearly.It’shardto motivate these stressed-out adults to do something differently, because they don’t think anything will work. And it’s hard to get them to remember what they are supposed to be doing differently in the first place, because under emotional distress, humans-especially those with ADHD-regress to destructive forms of thought and behavior.

Yet something must be done to deal with the dreadful homelife that so many families with ADHD experience. Advice and treatment from mental health professionals can help-if the pro- gram can only be implemented. Sometimes if a family can just find a few places to start, life at home will calm down and other, more complicated but useful solutions may become possible.

Since it’s one thing to make a suggestion to a family and quite another thing to get them to do what you suggest, the proposals in this chapter will share-as much as possible-several characteris- tics:

1. A down-to-earth understanding of ADHD households

2. Simplicity
3. Ease of application
4. More or less immediate results

Thomas W. Phelan

This may sound like another marketing pitch to an “ADHD-ogenic” society that many people feel is already spoiled rotten and can’t wait for any- thing. As a therapist you have to find something that parents, especially those with ADHD, will do. Lack of compliance can render even the most bril- liant suggestions useless (Stine, 1994). Compliance, or what is sometimes called treatment adherence, has to come first. The suggestions in this chapter are made from the point of view of someone who is both the parent of an ADHD adult and a clinical psychologist working with families in which ADHD is present. ADHD will always have a per- sonal, family side as well as a clinical and scientific side. To grasp the problem and deal effectivelywith it, you need to understand both.

Our first task in this chapter will be to take a nonclinical look at how ADHD traits-in both parents and children-conspire to affect family life in general as well as parenting in particular. Having described the problem, I’ll then propose some practical, straightforward ideas for trying to minimize stress in homes affected by ADHD.

EFFECTS OF ADHD ON HOME AND FAMILY Home Sweet Home

Whether they actually control it, all parents- whether suffering from A D H D or not-feel deeply responsible for the kind family atmosphere they provide. Parents want things to run smoothly at home and family members to get along. When A D H D is involved, however, family life is often characterized by conflict, anxiety, noise, and disor- ganization. And when anger and chaos seem to be more the norm than peace and harmony, moms and dads will blame themselves and blame each other.

Conflict

Since it’s difficult for people with ADHD to calmly discuss and resolve differences, conflict is

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the two youngsters would proceed to argue with each other about whose turn it was to talk. Next, mom (who had ADHD) would yell at the kids to be quiet. Dad would then reprimand his wife for screaming. These parents also related an intriguing fact: If you took any one person out of the picture at dinner-ither parent or any

more frequent at home-not just conflict, but ener- getic conflict. Domestic battles have an intensity about them that is impossible to ignore. After two parents both had difficult days at work, for in- stance, they may argue about how to manage the kids, while the kids are arguing about who gets to use the computer. Because genuine give- and-take negotiation is rare, attempts at conflict resolution are characterized more by various forms of testing and manipulation. Badgering, temper tantrums, threats, pouting, and sometimes even physical aggression are the more common methods people use to get their way. Husbands and wives with ADHD not only struggle to prevent or manage interpersonal conflict, but also add to it because of their predispositions toward restless- ness, impulsivity, impatience, and emotional over- arousal.

Anxiety

Persistent conflicts over months and years inev- itably give rise to a sense of tension and anxiety at home. If a fight or argument is not occurring right at the moment, it soon will be. Everyone feels a sense of negative anticipation. At the end of the day it’s hard to unwind when you feel the next bit of trouble is always right around the corner. For any single family member, it seems that the onl

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CIinicians’ Guide To Adult ADHD Assessment and Intervention