Cognitive Behavioral Therapy for Adult ADHD

An Integrative Psychosocial and Medical Approach

J. Russell Ramsay, Anthony L. Rostain

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781135072179
• Edition: 2
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Cognitive Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach has been revised, updated, and expanded for this second edition and remains the definitive book for clinicians seeking to treat adults with ADHD. Clinicians will continue to benefit from the presentation of an evidence-supported treatment approach for adults with ADHD that combines cognitive behavioral therapy and pharmacotherapy adapted for this challenging clinical population. The updated edition of the book offers new and expanded case examples, and the authors emphasize more detailed, clinician-friendly "how to" instructions for the delivery of specific interventions for adult patients with ADHD. Understanding that most adults with ADHD say, "I know exactly what I need to do, but I just cannot make myself do it, " the book pays special attention to the use of implementation strategies to help patients carry out the necessary coping skills to achieve improvements in functioning and well-being in their daily lives. In addition to providing an outline of their treatment approach, Drs. Ramsay and Rostain provide an up-to-date review of the current scientific understanding of the etiology, developmental course, and life outcomes of adults with ADHD as well as the components of an thorough diagnostic evaluation. As an added clinical resource, Drs. Ramsay and Rostain have also produced a companion patient handbook written for adults with ADHD, The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out, which clinicians can use with their patients.

1
Adult ADHD

Diagnosis, Symptoms, Etiology, and Assessment

LINDA is a 41-year-old married woman who said that she is probably still too young to have a midlife crisis, just yet. By all accounts, she is doing well in life, having a stable marriage and family life. Last year, both of her children reached an age that they were in school all day, giving Linda more free time during the day to do with as she pleased. She had a number of personal goals she wanted to pursue, including the possibility of completing the few remaining credits for her college degree. By the end of her children’s school year, however, Linda realized that not only had she not made progress on any of her objectives, but she also was at a loss to explain how she spent her time. A while ago, she had read a book on adult Attention-Deficit/Hyperactivity Disorder (ADHD) and thought that the accounts fit her life story but had never followed through on getting help. After breaking down in tears with her husband when discussing her frustrations, they agreed that she should seek out an evaluation for adult ADHD.

IAN is a 23-year-old college student “somewhere in (his) junior year” as he prepares to enter his sixth year of enrollment. He is seeking an evaluation for ADHD at the insistence of his family after having difficulties throughout college, including being placed on academic suspension after his first year. Ian’s parents had suspected he had ADHD when he was in middle school, but he always did “well enough” in school, often with their support and involvement. His path through college included often falling behind in his work, dropping and retaking many courses, leading to his being on track to be graduated when he is 25 years old. Watching the majority of his friends move on with their lives, Ian came to the realization that he was going to be “old” by the time he finished and now faces the more difficult upper-level courses required for his major, the combination of which led him to succumb to his parents’ wish that he get evaluation.

JASON is nearing his 30th birthday. He had always been described as “on the go” as a child and teenager. He was an average student throughout school, but his teachers often commented that his work and study habits were inconsistent. He channeled his energy into sports and was an accomplished athlete who never touched drugs or alcohol and was thought to be on track for a scholarship to play lacrosse in college. However, a string of serious injuries and surgeries derailed Jason’s athletic career. He got out of shape and eventually became addicted to the pain medications he was prescribed for his injuries. After stints in rehabilitation programs and other treatments, Jason was 9 months clean and sober, but he was living at home with his parents and had no structure to his life other than treatment appointments. Moreover, he seemed unable to follow through on suggestions from his counselor to find a job, enroll in school, or find some other worthwhile endeavor. His parents did some research on ADHD and addiction and thought it was worthwhile to have him go through an evaluation.

HAROLD is a 50-year-old married man who lives with his wife and two teenage children. He has a long history of serial employment working in sales but has been unemployed for the past year. Harold agreed to an evaluation after his wife Carol hinted at the possibility of a marital separation because she was frustrated by his lackadaisical approach to his job search despite their family’s dire financial situation. These issues were a central theme in their marital therapy where Carol expressed anger that she was the sole wage earner, financial manager, and organizer for the household. The marital therapist noted that Harold’s history sounded consistent with ADHD and recommended a formal evaluation. He agreed to the evaluation in order to appease Carol and noted that his brother and teenage nephew had been diagnosed with ADHD. Harold acknowledged the severity of the situation, the importance of this step of good faith to Carol and his children—and he promptly missed the evaluation appointment.

Introduction

I’ve tried to make the changes suggested by friends, doctors, and ADHD books, but they did not help me. I know exactly what I need to do, but I cannot do it. I could coach someone else about what to do but cannot follow my own advice. What is this treatment going to do for me that is any different than anything else I have already tried—and that has not worked?

Each of the patients described earlier, all of whom were diagnosed with ADHD in adulthood, asked this question in some form or another. This book represents an extended answer to this question, which is posed to us by most patients who come through our Adult ADHD Treatment and Research Program at the University of Pennsylvania’s Perelman School of Medicine.

The succinct answer that we offer to patients is that, being experienced with the assessment and treatment of adult ADHD, we are good at helping people get a more nuanced, personalized understanding of how they “do not do things.” From that understanding, we help individuals develop and use strategies and tactics that will promote effective coping by targeting the ways that ADHD interferes with their use. These strategies are composed of the coping skills patients have already unsuccessfully attempted to use on their own; therefore, we also emphasize implementation strategies to target the motivational and performance problems that adults with ADHD have in their daily lives. The implementation strategies also include steps or specific tactics for recognizing and working around the obvious (and some less obvious) barriers associated with ADHD. To this end, we have found the cognitive behavioral therapy (CBT) framework adapted to the unique issues faced by adults with ADHD to be an effective one, most often in combination with medication treatment.

However, before jumping into our review of the CBT model for adult ADHD and specific interventions in detail, it is important to have an understanding of ADHD and its effects on the individuals who seek treatment, such as those described above (not to mention the vast majority who do not receive specialized treatment for ADHD [Kessler et al., 2006]). As we do with our patients, it is important to understand the role of ADHD in how they do not do things. The goal of this chapter is to provide an overview of the official diagnostic criteria for ADHD and description of its symptoms and features. After introducing these symptoms, we will review research on the persistence of ADHD across the lifespan and its prevalence in the population, common comorbid conditions, and the life outcomes of adults with ADHD. We also will provide a brief review of the current science-based understanding of the underlying etiology of the observable features of ADHD and, lastly, an outline of the components of a comprehensive diagnostic evaluation for adult ADHD.

Before moving onto these sections, we want to address some of the factors that contribute to ADHD being viewed as a controversial diagnosis or one for which its validity is still in question in some quarters. Moreover, we want to provide an orientation toward the contemporary view of ADHD that informs assessment and treatment and the challenges in each of these clinical endeavors.

ADHD is an exquisitely puzzling and confounding condition. For those affected by ADHD, many aspects of daily life that most people take for granted are rendered more difficult. Adding to the frustration is the seeming inconsistency of performance, being able to function well in some situations but not in others. When witnessed in isolation, ADHD symptoms often appear as merely annoying nuisances or peculiarities to observers, contributing to the view that “everybody has ADHD.” However, the persistent and pervasive effects of ADHD symptoms can insidiously and severely interfere with the demonstration of one’s knowledge in an educational setting, fulfilling one’s potential in the workplace, establishing and maintaining interpersonal relationships, and simply having the self-efficacy to develop, follow through on, and achieve reasonable personal endeavors. No single “ADHD moment” is terribly disturbing, but the cumulative effect of a longstanding pattern of these troubles can be devastating.

By repeatedly interrupting one’s personal undertakings, ADHD punctuates many aspects of life from which individuals build a sense of self and identity. Thus, rather than being a “nuisance” condition, the breadth and depth of problems faced by persons with ADHD ranks the diagnosis among the most impairing conditions seen in outpatient behavioral healthcare.

ADHD is equally confounding for mental health professionals. Most clinicians have not received formal training in the assessment and treatment of ADHD, particularly in adult patients. Its symptoms are difficult to differentiate from other, more familiar psychiatric disorders, increasing the likelihood that features of ADHD will be overlooked if not patently dismissed. On the other hand, it is equally possible to wrongly diagnose ADHD based on a limited snapshot of a patient’s life and a handful of reported symptoms without adequately reviewing the relevant history of functioning and considering alternative causes of problems. The very moniker “attention deficit” can be misleading. Individuals with ADHD have the ability to pay attention to tasks that are interesting, rewarding, or otherwise compelling in some way, though they struggle with the effortful redirection and allocation of attention to less immediately salient tasks. These various complications in the process of identifying ADHD has led to it being among the first mentioned when discussions turn to controversial psychiatric diagnoses.

The symptoms of ADHD are particularly difficult to define because it is hard to draw a dissecting line across a continuum of functioning to mark where normal levels of behavior end and clinically significant difficulties begin. In psychology and psychiatry, issues are usually measured by differences in degree rather than a clear demarcation line. As Edmund Burke observed when considering the distinction between day and night, “though there be not a clear line between them, yet no one would deny that there is a difference” (cited in Hallowell & Ratey, 1994, p. 195).

During the writing of the revised edition of this book, the official diagnostic criteria defining ADHD were updated in the newest edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-5]; American Psychiatric Association [APA], 2013). Apart from some minor wording changes, the ADHD symptom criteria continue to be drawn from those established in studies of children and adolescent samples and do not adequately reflect recent research on adults with ADHD (McGough & Barkley, 2004).

Using the DSM-5 diagnostic criteria and guidelines as a framework, there are steps that can be taken to improve diagnostic accuracy, which we will discuss later in this chapter. The assessment process can be tricky to navigate, even for clinicians who are experts in adult ADHD. As a comparison, many physical or medical problems are identified relative to a specific event or injury (e.g., broken arm after being tackled in a football game), onset of symptoms (e.g., fever and nausea during the flu season), or other experiences that represent a noticeable change in normative physical functioning. In most cases, these symptoms can be localized to a specific physical system and likely only have circumscribed effects on activities associated with one’s sense of self (e.g., suspend playing football until the broken bone heals; bed rest for the flu).

Clinical psychology and psychiatry are fields in which the diagnostic process is complex because it is often more difficult to disentangle a change in functioning from one’s typical functioning. It is also difficult to pinpoint a definition of “normative functioning” in order to determine when an experience is atypical and requires attention. When does a low mood for several weeks after returning to work from a vacation reflect a major depressive episode rather than normal readjustment to a stressful job? When does having a shy temperament turn into social anxiety disorder? At what point does excessive “social” drinking become alcohol abuse?

The symptoms of ADHD are often difficult (though not impossible) to observe. The characteristic features of ADHD can be present but not yet causing problems to the degree that they are viewed as impairments. As has been noted elsewhere, ADHD can be thought of as akin to the wind—one does not really “see” the wind, but rather observes it in its effects, such as branches or loose papers moving in the breeze (Ramsay, 2010b). However, there is an undeniable continuum of wind intensity from light breeze to gale force winds. Moreover, the effects of the intensity of wind cannot be defined without consideration of the context. Relatively strong winds can be well managed by, if not beneficial to, someone piloting a sailboat; a stiff breeze, on the other hand, will be very disruptive to a yard sale or outdoor art show.

There are contemporary scientific models for understanding ADHD that help to increase its “visibility.” We and others contend that the “A” and the “H” in the ADHD acronym are misleading insofar as they represent circumscribed and incomplete examples of symptoms of ADHD that do not really define the condition. The situation is akin to Panic Disorder being renamed “Tachycardia Disorder.” The disorder would be reduced to a commonly observed but nonspecific feature of panic attacks rather than understanding the condition as the misfiring of the sympathetic nervous system in response to the perception of a threat.

ADHD is increasingly understood as a neurodevelopment syndrome characterized by poor self-regulation stemming from deficits in the executive functions (Barkley, 1997, 2012b; Brown, 2005, 2013). This formulation of ADHD and the specific behavioral manifestations of executive dysfunction in everyday life help to make this “invisible” syndrome visible to clinicians as well as to patients. There are additional scientifically sound models that help shed light on additional features of ADHD, such as motivation deficits, reward deficiencies, and alertness to environmental cues that help explain the complexity of ADHD. Moreover, they are most characteristic of the problems seen in adults with ADHD whose paths toward “maturity” are markedly delayed or derailed. Taken together, these diverse factors help to define self-regulation, which is at the heart of the frustration expressed by patients at the outset of this chapter—“I know exactly what I need to do, but I cannot do it.”

The rest of this chapter will be organized to introduce the current official diagnostic criteria for ADHD, a description of its symptoms and features, review of research on the persistence of ADHD across the lifespan and its prevalence in the population, common comorbid conditions, and the life outcomes of adults with ADHD. We also will provide a brief review of the current science-based understanding of the underlying etiology of the observable features of ADHD and, finally, the components of a comprehensive diagnostic evaluation for adult ADHD. The results of this sort of assessment inform the psychosocial and medication treatment approaches that will be the focus of the remaining chapters of this book.

Diagnostic Criteria and Symptoms Across the Lifespan

The DSM-5 (APA, 2013) represents an update on the diagnostic criteria in light of research that has occurred in the nearly 20 years since the most recent substantive revisions (i.e., DSM-IV; APA, 1994). ADHD is listed in the newly designated section on neurodevelopmental disorders. The very fact that neurodevelopmental disorders have been acknowledged as distinct from other diagnostic categories represents a progressive change in diagnostic conceptualization.

The first, most long-awaited change has been to raise the age-of-onset criteria. The DSM-5 requires that “several” relevant symptoms be present before the age of 12, replacing the previous 7-years-old age of onset criterion. There is no requirement that full diagnostic criteria be met or that impairments necessarily are experienced by that age, acknowledging the developmental course of the condition; rather, the purpose of the age change is to recognize that full symptomatic expression and associated impairments may occur after childhood or adolescence in many cases (Faraone et al., 2006; Polanczyk et al., 2010). In fact, an evidence-based case can be made to set the threshold at 16 years old (Barkley, Murphy, & Fischer, 2008).

Second, the term presentations replaces the use of types to identify that there are differences in the constellation of symptoms reported by patients, but stopping short of the suggestion that these different constellations necessarily reflect distinct and well-established clinical categories (i.e., predominantly inattentive presentation, predominantly hyperactive/impulsive presentation, and combined presentation).

During the preliminary versions of the DSM-5, a fourth presentation category had been drafted, deemed the inattentive presentation (restrictive). This category was defined as the presence of inattention symptoms in number and severity that exceeded the diagnostic threshold but with endorsement of no more than two symptoms of hyperactivity/impulsivity symptoms. The restrictive inattention presentation seemed designed to identify those individuals with pure inattention symptoms without behavioral disinhibition, though it was not retained in the final edition. A strong case can be made that purely inattentive manifestation of ADHD represents a distinct condition from the combined presentation (Milich, Balentine, & Lynam, 2001; Nigg, 2006; Roberts & Milich, 2013). Distinct difficulties associated with attentional engagement often coexist with inattentive symptoms in a category previously known as Sluggish Cognitive Tempo, but that will likely be renamed as Concentration Deficit Disorder (Barkley, 2013), which will be discussed in more detail later.

The 18 symptoms of ADHD and their wording are virtually unchanged from the DSM-IV. There have been some superficial wording changes and there are new and improved exemplars of symptoms that are relevant for adults with ADHD. For example, “Often runs about or climbs in situations where it is inappropriate” is accompanied by a note that “in adolescents or adults, may be limited to feeling restless.” Similarly, the list of inattention symptoms includes examples of difficulties with time management, disorganization, and distractibility that are relevant for adults with ADHD. Of course, these examples are very familiar to clinicians experienced in the assessment and treatment of adult ADHD but should provide some improved guidance to other healthcare...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgments
• 1 Adult ADHD: Diagnosis, Symptoms, Etiology, and Assessment
• 2 Models of Treatment: Cognitive Behavioral Therapy and Pharmacotherapy for Adult ADHD
• 3 Research Evidence for CBT and Medications for Adult ADHD
• 4 Clinical Case Examples
• 5 Complicating Factors
• 6 Maintenance and Follow-Up
• Appendix A: Informational Resources About Adult ADHD
• Appendix B: Outline of a Typical CBT Session for Adult ADHD
• Appendix C: Outline of a 20-Session/6-Month Course of CBT for Adult ADHD
• Appendix D: Typical Medications Prescribed to Treat Adult ADHD
• References
• Index