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Downloaded by [New York University] at 12:14 14 August 2016 Cognitive-Behavioral Therapy for Adult ADHD Downloaded by [New York University] at 12:14 14 August 2016 Cognitive-Behavioral Therapy for Adult ADHD 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 Attention-Deficit/ Hyperactivity Disorder (ADHD). Clinicians will continue to benefit from the presenta- tion 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 function- ing and well-being in their daily lives. In addition to providing an outline of their treat- ment 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 a 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. J. Russell Ramsay, PhD, is cofounder and codirector of the Adult ADHD Treatment and Research Program and an associate professor of clinical psychology in psychiatry in the University of Pennsylvania’s Perelman School of Medicine. He is cochair of the profes- Downloaded by [New York University] at 12:14 14 August 2016 sional advisory board for the Attention Deficit Disorder Association. Anthony L. Rostain, MD, is cofounder and codirector of the Adult ADHD Treatment and Research Program and a professor of psychiatry and pediatrics in the University of Pennsylvania’s Perelman School of Medicine, where he is also director of education for the department of psychiatry. He is currently president of the American Professional Society of ADHD and Related Disorders (APSARD). This page intentionally left blank Downloaded by [New York University] at 12:14 14 August 2016 Cognitive-Behavioral Therapy for Adult ADHD An Integrative Psychosocial and Medical Approach Second Edition J. Russell Ramsay and Anthony L. Rostain Downloaded by [New York University] at 12:14 14 August 2016 Second edition published 2015 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2015 J. Russell Ramsay and Anthony L. Rostain The right of J. Russell Ramsay and Anthony L. Rostain to be identified as authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. First edition published by Routledge 2008 Library of Congress Cataloging-in-Publication Data Ramsay, J. Russell, author. Cognitive-behavioral therapy for adult ADHD : an integrative psychosocial and medical approach / by J. Russell Ramsay and Anthony L. Rostain. — Second edition. p. ; cm. Includes bibliographical references and index. I. Rostain, Anthony L., author. II. Title. [DNLM: 1. Attention Deficit Disorder with Hyperactivity—therapy—Case Reports. 2. Cognitive Therapy—methods— Case Reports. WM 165] RC394.A85 616.85′89—dc23 2014014144 ISBN: 978-0-415-81590-1 (hbk) ISBN: 978-0-415-81591-8 (pbk) ISBN: 978-0-203-37548-8 (ebk) Typeset in Minion by Apex CoVantage, LLC Downloaded by [New York University] at 12:14 14 August 2016 JRR dedicates this book to my beloved daughters, Abigail and Brynn Ramsay. ALR dedicates this book to my wonderful kids, Isabelle, Julian, Sam, and Gen who have taught me what it really means to be a dad. Downloaded by [New York University] at 12:14 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 12:14 14 August 2016 Contents Preface xi Acknowledgments xv 1 Adult ADHD: Diagnosis, Symptoms, Etiology, and Assessment 1 Introduction 2 Diagnostic Criteria and Symptoms Across the Lifespan 5 ADHD, Predominantly Hyperactive/Impulsive Presentation 7 ADHD, Predominantly Inattentive Presentation 8 ADHD, Combined Presentation 10 Other Specified ADHD and Unspecified ADHD 11 Sluggish Cognitive Tempo/Concentration Deficit Disorder 11 Persistence and Prevalence of Adult ADHD 12 Psychiatric Comorbidity and Adult ADHD 15 Life Outcomes of Adults With ADHD 16 Etiologic Models for ADHD 18 Executive Dysfunction Model of ADHD 19 Genetics 21 Neurobiology 22 Default Mode Network 24 Dopamine Model of Motivation 25 Assessment of Adult ADHD 26 Phone Screen/Home Packet/Clinical and Background Questionnaires 26 Downloaded by [New York University] at 12:14 14 August 2016 Review and History of Presenting Problems 27 Developmental History 27 Family History/Preschool Functioning 27 Academic History 28 Vocational History 29 Medical and Psychiatric History 29 Structured Diagnostic Interview 30 Assessing Symptoms of ADHD and Related Features 31 Inquiring About ADHD Symptoms 31 Standardized ADHD Symptom Checklists 32 viii Contents Standardized Adult ADHD Symptom Rating Scales 33 Standardized Ratings of Executive Functioning 34 Ratings of Functional Impairments 35 Mood and Anxiety Ratings 36 Neuropsychological Screening 36 Adult ADHD and Comorbidity 38 Depression 39 Anxiety 39 Bipolar Disorder 40 Substance Abuse 41 Oppositional Defiant Presentations in Adults With ADHD 42 Developmental-Social Learning Disorders 43 Chapter Summary 44 2 Models of Treatment: Cognitive Behavioral Therapy and Pharmacotherapy for Adult ADHD 46 Cognitive Behavioral Therapy for Adult ADHD 46 Case Conceptualization 48 Neurobiology and Environment Interaction 50 Developmental Experiences 52 Schema and Core Beliefs 53 Compensatory Strategies 54 Automatic Thoughts, Emotions, and Behaviors 57 CBT for Adult ADHD in Clinical Practice 59 Development of the PENN CBT for Adult ADHD Model 59 Reactions to the Diagnosis of ADHD 60 Motivation and Readiness for Change 62 Psycho-education 63 Defining Treatment Goals 63 Therapeutic Alliance 65 Session Structure 67 “Starting Small” 68 Categories of Interventions 70 Downloaded by [New York University] at 12:14 14 August 2016 Cognitive Interventions 70 Changing Automatic Thoughts 70 Changing Core Beliefs and Schemas 75 Behavioral Interventions 78 Implementation Strategies 81 Acceptance-Mindfulness Interventions 84 Specific Interventions for Managing Adult ADHD 86 To-Do List 86 Daily Planner 89 Time and Task Management 90 Getting Started 93 Contents ix Keeping the Plan Going (Part 1): Motivation, Emotions, and Energy 96 Keeping the Plan Going (Part 2): Attitudes, Beliefs, and Self-Esteem 99 Outsourcing Coping Skills 102 Data Management 103 Materials Management 105 Environmental Engineering 106 Problem Management/Decision Making 107 CBT Summary 110 Pharmacotherapy for Adult ADHD 111 Pharmacotherapy Summary 115 Chapter Summary 115 3 Research Evidence for CBT and Medications for Adult ADHD 116 Review of Research Evidence for Psychosocial Treatments for Adult ADHD 118 Individual CBT Approaches 119 Open and Nonrandomized Studies of Individual CBT 119 Randomized Control Studies of Individual CBT 121 Group CBT Approaches 123 Open and Nonrandomized Studies of Group CBT 123 Randomized Control Studies of Group CBT 126 Miscellaneous Psychosocial Treatments 129 Psychosocial Treatment Summary 131 Review of Research Evidence for Pharmacotherapy for Adult ADHD 131 Stimulant Medications 132 Nonstimulant Medications 132 Pharmacotherapy Summary 134 Chapter Summary 135 4 Clinical Case Examples 136 Case Example 1: Linda 136 Assessment 137 Course of Treatment 139 CBT 139 Downloaded by [New York University] at 12:14 14 August 2016 Pharmacotherapy 143 Case Example 2: Ian 144 Assessment 144 Course of Treatment 147 Pharmacotherapy 147 CBT 147 Case Example 3: Jason 152 Assessment 153 Course of Treatment 155 Pharmacotherapy 155 CBT 156 x Contents Case Example 4: Harold 159 Assessment 159 Course of Treatment 163 Pharmacotherapy 163 CBT 164 5 Complicating Factors 169 Readiness for Change and Motivational Enhancement in CBT 169 Treatment Complicating Behaviors 171 Lying 172 Adult Oppositional Behavior 175 Physical and Medical Well-Being 177 Exercise 179 Sleep 179 Dealing With Technology 180 Professionals’ Reactions to ADHD Patients 182 Significant Impairment 185 Medication-Related Complications 187 Chapter Summary 189 6 Maintenance and Follow-Up 190 Maintenance and Follow-Up: CBT 191 Winding Down in CBT 193 Wrapping Up and Booster Sessions 194 Reengagement in CBT 195 Important Coping Strategies and Resources to Use After
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