Downloaded by [New York University] at 12:14 14 August 2016 Cognitive-Behavioral Therapy for Adult ADHD

Home , Attention span, Saving Max, Sluggish cognitive tempo

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 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 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 the End of CBT 196 Self-Advocacy, Assertiveness, and Asking for Help 196 Community Support/Psycho-education 197 Commitment to the Long-Term Management of ADHD 198 Maintenance and Follow-Up: Pharmacotherapy 199 Chapter Summary 200

Appendix A: Informational Resources About Adult ADHD 201 Downloaded by [New York University] at 12:14 14 August 2016 Online Resources and Organizations Regarding Adult ADHD 201 Recommended Readings About Adult ADHD: For Consumers 201 Recommended Readings About Adult ADHD: For Clinicians 202 CBT for Adult ADHD: Treatment Manuals 202 Appendix B: Outline of a Typical CBT Session for Adult ADHD 204 App endix C: Outline of a 20-Session/6-Month Course of CBT for Adult ADHD 205 Appendix D: Typical Medications Prescribed to Treat Adult ADHD 207 References 210 Index 229 Preface

The book The Time Traveler’s Wife (Niffenegger, 2003) tells the story of Henry DeTamble, a man with a genetic disorder (“Chrono-Impairment”) that causes him to suddenly and unexpectedly travel back and forth throughout times of his life. Being unable to carry anything with him, he must start over wherever he lands in the timeline of his life. Stress- ful events activate his transport and he finds ways to survive and even find love in a woman, Clare, who eventually becomes his wife and they piece together a relationship from their periodic encounters. Among many other themes in the novel, Henry expends so much of his life dealing with the unpredictability of his circumstances and merely trying to get by that he has a hard time knitting together a coherent sense of life and a relationship due to his sense of time being repeatedly and capriciously fragmented. There would not seem to be many parallels between a time-traveling love story and Attention-Deficit/Hyperactivity Disorder (ADHD). ADHD is a lifelong neurodevelopmental syndrome that is often associated with disinhibition and untethered thoughts and actions, which are, in fact, some of the more common features. However, underlying these symptoms is the fact that ADHD is a problem related to poor self-regulation, which results in the sense that various important endeavors and aspects of life are repeatedly and suddenly punctuated and knocked off course. What was tragic about Henry DeTamble’s situation is that he had problems being able to follow a course of life in which he could move toward and enjoy coherent moments, relationships, and ventures, and otherwise enacting his intentions due to his condition. For adults with ADHD, the struggle is that they have difficulties consistently following through on valued plans for which they are capable to perform and despite the recognition of the importance of these plans. Or, using the description voiced by patients that will be repeated throughout this vol-

Downloaded by [New York University] at 12:14 14 August 2016 ume, “I know exactly what I need to do, but I just do not do it.” Although sharing a diagnosis of ADHD, there are likely different developmental pathways for the onset of symptoms that likely map onto different trajectories for the development of different brain networks. There are different symptom profiles and clinical presentations of symptoms as well as coexisting conditions. However, there also are myriad ways to “not do things” that create problems in daily life for adults with ADHD. What is more, ADHD is a neurodevelopmental syndrome, which means that the difficulties do not occur in discrete episodes, such as is the case in depression or panic attacks. Rather, ADHD represents ongoing delays or difficulties that are inconsistent with a particular developmental stage. There have been some studies following children with ADHD into adulthood in which individuals have been found to be in remission in xii Preface terms of being asymptomatic, but they may still suffer the ongoing effects of previous difficulties in terms of limitations in adulthood functioning. Thus, even those who may outgrow ADHD may not be able to “outrun” it. A lifetime diagnosis of ADHD puts one at risk for a host of impairments in multiple life domains. The condition is associated with wide-ranging functional difficulties of varying severity that can be quite disruptive and require active steps to manage. More- over, the very self-regulation difficulties that interfere with functioning also interfere with following through with treatment. We are clinician-researchers, a psychologist and a psychiatrist, who specialize in the diagnosis and treatment of adult ADHD. We cofounded and continue to codirect the Adult ADHD Treatment and Research Program at the University of Pennsylvania Perelman School of Medicine. When we started the program in 1999, there was little empirical guidance for the treatment of adult ADHD. There was some research on medication treatments for adult ADHD drawing on treatment approaches and medications used for children with ADHD, although the range of options was more limited than it is now. At that time, there were no outcome studies of psychosocial treatments for adult ADHD. Our primary mission for the program was to compile a rigorous, comprehensive diagnostic assessment with which to accurately identify adults with ADHD, and to develop a combination treatment comprised of pharmacotherapy and psychosocial treatment. It seemed to us and to our professional colleagues who arrived at a similar and independent conclusion that cognitive behavioral therapy (CBT) offered a model of psychosocial treatment that could be adapted to the needs of adults with ADHD and could be shared with other clinicians. Being practicing clinicians, we also realized the need to be able to personalize treatment to the individual needs, symptom profiles, and temperament of each patient. Thus, another mission of ours was to develop treatments that were empirically supported and clinically useful. The first edition of this book represents a summary of our combined treatment approach for adults with ADHD at that time. It drew on our clinical experience as well as a published outcome study (Rostain & Ramsay, 2006c). While the basic model of treatment will be familiar to readers of the first edition, the intervening years have seen many positive developments in the conceptualization of adult ADHD as well as in its treatment with both medications and CBT. We hope this new edition of the book will continue to be relevant for many readers and will provide new insights, even for readers of the first edition. As before, we have written it as a clinician-friendly resource for experienced mental health professionals who seek guidance for structur-

Downloaded by [New York University] at 12:14 14 August 2016 ing treatment with their adult patients with ADHD. The revised edition reflects our ongoing interest in and emphasis on implementation strategies, the interventions used to help increase the likelihood that patients employ the coping skills reviewed in the consulting room. Said differently, these approaches are designed to make treatment “sticky,” making sure that patients employ their coping skills at the “point of performance.” We have elaborated some of the specific interventions we use in our clinical work, expanding on our interest in implementation strategies directed at helping adults with ADHD follow through on the use of coping strategies in the face of a condition that makes follow-through difficult. Despite the fact that ADHD is not the result of negative thinking, we continue to find that cognitive modification interventions are essential to Preface xiii the overall CBT approach for ADHD and, in particular, to address the motivational deficits seen in adult ADHD. Another mission of our Adult ADHD Treatment and Research Program is clinical education. It is hoped that this second edition of the book will be a resource for clinicians-in-training and in clinical training programs for mental health clinicians. Seasoned professionals who are not experienced with the treatment of adult ADHD might also find it helpful in their work. We have been encouraged by the number of published outcome studies on psychosocial treatments for adult ADHD that have appeared in the years since we started our program and education. We hope our book will contribute to the growing empirical discussion, and we plan to continue conducting clinical studies in the future. The first chapter provides a description of symptoms seen in adult ADHD patients, of commonly encountered comorbid disorders, of daily functioning problems experienced by these patients, of information about the prevalence of adult ADHD, and of current scientific data and theories regarding its etiology. Special attention is paid to the changes made to the ADHD diagnosis in DSM-5 (American Psychiatric Association, 2013) as well as recent research on executive functions, motivational deficits, and neural networks implicated in ADHD. The first chapter culminates with a review of the essential components of a comprehensive diagnostic evaluation for adult ADHD that can set the stage for treatment. The second chapter focuses on describing treatment strategies commonly used for adults with ADHD. We provide a summary of our CBT framework for understanding and treating adult ADHD, including the use of the case conceptualization to maintain an overarching view of the many factors affecting a patient’s functioning. There is further elaboration on specific interventions and how to promote their implementation after patients leave the consulting room. Pharmacologic strategies for the treatment of the core symptoms of ADHD and of comorbid conditions are reviewed. A fundamental assumption of this approach is that patients must learn to cope with their ADHD in ways that make most sense to them. Finally, we outline a course of combined treatment using both medications and CBT, including specific cognitive, behavioral, and skill- based interventions within a 20-session model of treatment extending over about 6 months. Although we acknowledge that this time frame may not be applicable for certain patients—some may require fewer sessions, some may require many more sessions—it is a useful heuristic for thinking about setting up therapy. Chapter 3 reviews the current research support for the different treatments discussed

Downloaded by [New York University] at 12:14 14 August 2016 in Chapter 2 . There are many more outcome studies of psychosocial treatments for adult ADHD, including several randomized controlled designs. There also have been new medications approved for use since the first edition of the book and ongoing pharmacologic outcome studies. Chapter 4 focuses on presenting four new case examples with which we illustrate commonly encountered presenting problems, assessment procedures, and our combined treatment approach in action. We have chosen some of the more common presenting issues and clinical challenges, including a case in which the patient was in and out of treatment. Chapter 5 reviews complicating factors that may arise in the course of treatment of adult ADHD. Among the issues discussed are how the symptoms of ADHD affect xiv Preface treatment adherence and follow-through (e.g., forgetting appointments, poor follow- through on therapy homework), handling patients’ misuse of medications (both under- utilization and abuse), dealing with comorbid disorders and substance abuse, addressing patients’ sensitivity to failure and rejection, contending with unrealistic expectations for what treatment can offer, and managing the therapeutic alliance (including common mistakes made by therapists). The sixth and final chapter addresses issues related to preventing relapse and helping patients maintain their effective coping after treatment ends. We make clear that the goal of CBT is “to make the therapist obsolete” by empowering patients to use their coping strategies independently, to make lifestyle changes in order to learn to manage their ADHD symptoms, and, when necessary, to seek help in the form of booster sessions or other assistance. We also discuss how to address various factors related to the long-term use of medications to manage ADHD symptoms. The appendices provide readers with quick references for additional resources to provide to their patients, such as reputable self-help books and websites. Additionally, we have provided tables outlining (1) a typical session of CBT for adult ADHD; (2) a 20-session course of CBT; (3) commonly prescribed medications, dose range, and side effects. ADHD can be an exquisitely confounding disorder. For those who suffer from it, ADHD makes the mundane details of life difficult and the anticipated challenges of life seem insurmountable, leading many to feel that they are not fulfilling their potential or have “failed” in life. For clinicians who want to help these patients, ADHD adds layers of complexity to assessment and treatment, and poses challenges to standard pharmacotherapy and psychotherapy approaches. We hope that this volume will prove useful by helping clinicians to better understand the symptoms of adult ADHD, to formulate more effective treatment plans, and to assist their patients as they attempt to achieve their goals. By doing so, we hope it will be helpful for students, supervisors, clinicians, and, most importantly, for adults living with ADHD.

Downloaded by [New York University] at 12:14 14 August 2016 Acknowledgments

The authors wish to thank many individuals, without whom the development and completion of the second edition of Cognitive-Behavioral Therapy for Adult ADHD would not have been possible. The Adult ADHD Treatment and Research Program at the Uni- versity of Pennsylvania continues to be indebted to several individuals who were willing to invest in the notion of starting a specialty clinical program. Mr. Fred Shvetz, Mr. and Mrs. David Toomim, and Mr. Jack Parker all separately made generous gifts at crucial points in the development of our program in support of our ongoing mission to develop better treatments and to give away our knowledge to other professionals and to the public. We hope the fact that we are well into our second decade of operation, have produced the second edition of this book, and that the program continues to grow lets them know that their initial investments continue to reap dividends for patients with adult ADHD. We wish to thank our colleagues in the Department of Psychiatry at the University of Pennsylvania School of Medicine, and its Chairman, Dwight L. Evans, M.D., who create a professional environment that encourages the pursuit of clinically relevant research that makes a difference in the lives of our patients. We also owe a deep debt of gratitude to the many individuals who have been a part of the Adult ADHD Treatment and Research Program over the years, which now number too many to cite by name. We have benefitted from the work of talented intake coordinators and assessors, many of whom have moved on to the next level of their training or have established their own clinical careers. There are many other professional colleagues affiliated with our program with whom we collaborate on various research, clinical, and educational projects, and we greatly value these relationships and partnerships. The administrative staff and various operations professionals at Penn (who we all know really are the ones who get things

Downloaded by [New York University] at 12:14 14 August 2016 done) also deserve our gratitude, most recently: Michele Cepparulo, Bridget Callaghan, Erin Sweeney, Joseph Dellaripa, Rebecca Goodman, Charnay Pugh-Arrignton, Lynn McCreary, Caroline Hamilton, and Rosellen Taraborelli (and many others who have stepped in and helped us out in a pinch). A key mission of our program is to train the next generation of mental health professionals who are interested in gaining experience in the assessment and treatment of adult ADHD. In recent years, we have had the good fortune to work with a number of talented psychiatry residents and advanced clinical psychology graduate student clinicians who have helped expand our services and have contributed to an intellectually stimulating work environment. xvi Acknowledgments We wish to thank Routledge/Taylor & Francis Group for supporting us throughout the process of putting together the first edition of the book, approaching us to provide an updated edition, and being game when we proposed a companion clinical handbook to go along with the revised treatment manual. Mr. Dana Bliss originally approached us about writing our first book and got us started on this second edition. Working with Dana on these projects was rewarding on both a professional and personal basis. We were saddened when Dana left Routledge, but the transition to working with Anna Moore has been seamless and equally productive. Finally, we wish to acknowledge the patients living with ADHD whom we have been privileged to serve since our program started in 1999. We have been privileged to witness their resilience and dignity in managing and ultimately transcending the effects of ADHD. JRR would also like to thank two of my teachers, whose influence continues to reap dividends on my career. Dr. Leonard I. Jacobson, my undergraduate mentor, and Dr. Anita L. Greene, my dissertation chair and graduate advisor, who were wonderful role models for maintaining high standards of professionalism in both research and clinical work. My predoctoral internship at CPC Behavioral Healthcare in Red Bank, NJ, and my postdoctoral fellowship at the Center for Cognitive Therapy at the University of Pennsylvania also provided me with wonderful training. I continue to be one of the senior clinical staff at the Center for Cognitive Therapy where the Director, Dr. Cory Newman, and other colleagues make it a rewarding workplace. The first meeting about what would become the Penn Adult ADHD Treatment and Research Program was held on March 8, 1999. Walking into Dr. Anthony Rostain’s office that day, I had no preconceived notions about having anything to do with adult ADHD. That meeting subsequently steered my career in a wonderful direction that continues to be fascinating, confounding, challenging, and fulfilling. As I tell people, Tony and I hit it off immediately because everything interests both of us and neither of us can say no to a challenge. My ongoing collaboration with Tony continues to be gratifying and close, both professionally and personally. The regard with which we hold each other was best expressed by an attendee at a work- shop we copresented. This professional colleague from another academic institution remarked, “You would not see a psychologist and a psychiatrist from my department present together, much less get along as well as you two do.” We share mutual respect, regard, high professional standards, and an ongoing commitment to the mission for our adult ADHD program.

Downloaded by [New York University] at 12:14 14 August 2016 A special word of thanks goes out to everyone at Main Street Java in Souderton, PA. This setting provided the perfect combination of coffee, free Wi-Fi, great food, a good workspace, and super friendly staff. Virtually all of this book and the companion patient handbook were written there, and I imagine it will be the site for many future projects. I have had the benefit of the support of many friends and family who have helped me maintain balance in my life. Most of my longest standing friendships have been with my teammates on the Jeff’s Demos soccer team, many of whom I have known for over half of my life, and I continue to treasure these connections. My parents, Mary Ann Ramsay and the late J. Roger Ramsay always supported my educational pursuits. My sister, Jennifer Ramsay, has also been a source of support. Acknowledgments xvii My biggest debt of gratitude goes to my wife, Amy, and my daughters, Abby and Brynn. Abby and Brynn are now teenagers in high school, each possessing unique talents, a keen intellect, and are well on their way to being strong, independent women. Finally, I have not had a first date since I was 23 years old, and since that night out, Amy has been with me for every worthwhile moment in my adult life. Whether we are doing something or doing nothing, I still enjoy hanging out with my wife. ALR would also like to thank the mentors who offered me boundless support and encouragement when I first began taking care of ADHD patients at The Children’s Hospital of Philadelphia in the mid-1980s: the late David Cornfeld, M.D., the late Robert Leopold, M.D., Alberto Serrano, M.D., and A. John Sargent, M.D. Their intellectual companionship and professional advice were invaluable in fostering my development into a truly bio-psycho-social developmentally oriented family systems clinician and researcher. I also want to recognize the close collaborative relationships that grew up around the founding of the CHOP ADHD program by thanking my colleagues Tom Power, Ph.D., Susan Levy, M.D., Marianne Glanzmann, M.D., and Larry Brown, M.D. No small debt of gratitude is also owed to my professional colleagues and friends at the Philadelphia Child Guidance Clinic who understood the importance of developing new approaches to ADHD within a systems-oriented framework that enabled me to broaden my view of the nature of the disorder and its treatment. A special note of thanks is due to my teachers and colleagues in the Department of Psy- chiatry of the University of Pennsylvania who enabled me to make the transition from pediatrics and child and adolescent psychiatry into the world of adult psychiatry: Peter Whybrow, M.D., Gary Gottlieb, M.D., James Stinnett, M.D., Trevor Price, M.D., Steve Arnold, M.D., Paul Moberg, Ph.D., and George Ruff, M.D. Equally important in the evolution of my “lifespan neurodevelopmental approach” to psychiatry have been the Penn psychiatry residents and CHOP child and adolescent psychiatry fellows whose enthusiasm for learning how to care for patients with ADHD is a constant source of inspiration. Of central importance in the evolution of my work with ADHD adults has been my relationship with Dr. J. Russell Ramsay who is my closest professional colleague, partner and coconspirator. It is hard to describe how naturally our teamwork has evolved over the 15 years we have worked together, and how exciting it has been to develop our approach to treating adults with ADHD and related disorders. Russ is an incredibly talented therapist, a diligent and hardworking researcher, a remarkably intelligent thinker, and one of the funniest people I know. His energy, enthusiasm, modesty, good nature,

Downloaded by [New York University] at 12:14 14 August 2016 and positive attitude have made it both rewarding and fun to work and to travel to the far reaches of the globe together. In the intervening time since the publication of our first book, Russ has become one of the most accomplished and highly recognized authorities on the psychosocial treatment of ADHD adults. The second edition of this book along with the clinical handbook would not have seen the light of day without his tireless devotion to this project. I am extremely fortunate to be blessed with the most wonderful family and friends that anyone could ask for. I am thankful for the love and support of my parents, Jacques and Gita; my stepfather, Sol; and my siblings: Carine, Tanina, Alain, Laura and David. I also want to salute my friends whose comradeship has gotten me through the best and xviii Acknowledgments worst of times, especially Mike Felsen, Louis Freedberg, Rob Hoffnung, Red Schiller, Gene Beresin, David Kaye, Chris Thomas, and Michael Silver. I especially want to recognize the incredible love and boundless support of my wife, Michele Goldfarb, who has been my closest friend and my greatest source of inspiration for over 17 years. Her generosity of spirit and her loving kindness have been constant and unwavering throughout the roller coaster ride of this past decade. And finally, I want to give special thanks to my children, Isabelle and Julian, whose love has given my life special meaning and immeasurable joy; and to my stepchildren, Sam and Gen, who have allowed me to become an important part of their lives, for which I am grateful beyond words.

Downloaded by [New York University] at 12:14 14 August 2016 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 insis- tence 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.

Downloaded by [New York University] at 12:14 14 August 2016 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 2 Adult ADHD 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 Perel- man 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 perfor-

Downloaded by [New York University] at 12:14 14 August 2016 mance 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 Adult ADHD 3 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

Downloaded by [New York University] at 12:14 14 August 2016 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, 4 Adult ADHD “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 Man- ual 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

Downloaded by [New York University] at 12:14 14 August 2016 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, Adult ADHD 5 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 revi- sions (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

Downloaded by [New York University] at 12:14 14 August 2016 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/ 6 Adult ADHD 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 professionals who may perform screenings. Third, the symptom threshold for diagnosing ADHD in adults has been lowered, though only slightly. Whereas DSM-IV required the presence of six out of nine symptoms of one of the subtypes to fulfill diagnostic criteria for patients of all ages, the revised threshold for older adolescents and adult patients is five out of nine symptoms of either one of the presentation types. A threshold of four symptoms has been shown to be sufficient to reliably differentiate individuals endorsing symptoms at a clinically significant level (i.e., 1.5 standard deviations above the mean) compared with normative ratings for adults (Barkley, Fischer, Smallish, & Fletcher, 2002). Although it is not reflected in DSM-5, an evidence-based case can be made for a separate set of diagnostic criteria for adult ADHD from those used for children and adolescents. Multiple lines of research have identified symptoms of executive dysfunction, symptom criteria that differentiate adult ADHD from community and clinical control groups, and criteria that are consistent with the reliable diagnostic factors that are relevant to identifying adults with ADHD (Barkley et al., 2008; Fedele, Hartung, Canu, & Wilkowski, 2010; Kessler et al., 2010). The fact that these symptoms are specific to adults, offer clearer behavioral analogs for identification, and can be assessed with norm-based

Downloaded by [New York University] at 12:14 14 August 2016 self- and other-report inventories make them appealing in the evaluation process as an adjunct to the official DSM-5 criteria. Considering that the diagnosis of ADHD affects some disability determinations, assessment of the need for academic or workplace accommodations, and treatment decisions, the introduction of severity specifications in DSM-5 is a positive development. In addition to identifying the specific presentation of ADHD symptoms, a severity level is assigned, namely mild, moderate, or severe symptoms or functional impairments. The diagnosis can also be specified as “in partial remission” to reflect residual symptoms of ADHD and ongoing impairment in a case in which full criteria had previously been met. Evaluators are encouraged to gather ancillary information about the developmental onset of symptoms in an attempt to offset difficulties with recall of historical information, Adult ADHD 7 which is consistent with similar advice in DSM-IV, though the recommendation is more strongly emphasized in the new edition. Corroborative information and additional infor- mants are also recommended in order to establish impairments in multiple domains of life and has long been considered a feature of a gold-standard assessment for adult ADHD. Finally, Pervasive Developmental Disorder has been eliminated from the exclusion criteria, reflecting the recognition that ADHD and Autistic Spectrum Disorders may coexist. It should be noted that DSM-5 was published during the writing of this edition of the book. Thus, there has not been adequate time for research and clinical practice to adjust to and integrate these new criteria. However, the actual symptom criteria and definitions are virtually unchanged. Consequently, our discussion of the different ADHD “presentations” will be based on research and observations of previous ADHD “types,” but the points made continue to be relevant for assessment and intervention.

ADHD, Predominantly Hyperactive/Impulsive Presentation It is the hyperactive and impulsive behaviors that are often considered the quintessential features of ADHD, particularly for children with ADHD. In fact, the purely hyperactive/ impulsive presentation is the least common, affecting less than 15% of all individuals with ADHD (Wilens, Biederman, & Spencer, 2002; Wilens et al., 2009). This presentation reflects the existence of behavioral disinhibition and impulsivity without the cognitive and other executive functioning difficulties associated with the inattentive symptoms. Adults exhibit fewer observable hyperactivity/impulsivity features, and it is rare that an adult will present for treatment with this presentation without corresponding attention problems. Usually these symptoms coexist with or are a precursor for the inattentive symptoms. They are also present in other psychiatric conditions, such as motor tics, manic episodes, or drug abuse. Hyperactive-impulsive symptoms (either alone or as part of the combined presentation), particularly when combined with Conduct Disorder, is associated with increased risk for additional psychiatric, substance use, and behavioral problems. Individuals with the hyperactive-impulsive and combined presentations often experience greater emotional and behavioral impairments in all stages of life than do individuals with the predominantly inattentive presentation (Barkley & Fischer, 2010, 2011; Barkley et al., 2008; Satterfield et al., 2007). Using the notion of ADHD as a problem of self-regulation, these findings are consistent with research showing that self-control differences in childhood are predict similar self-control differences and functioning in adulthood (Mischel,

Downloaded by [New York University] at 12:14 14 August 2016 Shoda, & Rodriguez, 1989; Mischel et al., 2011). The observation that older adolescents and adults with ADHD only rarely manifest observable levels of hyperactivity-impulsivity lent credence to the now-antiquated and inaccurate bromide that children with ADHD will eventually and inexorably “grow out of it.” While there is a reduction in overt signs of hyperactivity and impulsivity with age (Barkley, 2006; Wender, 1995, 2000; Wilens et al., 2002; Wilens et al., 2009), ADHD adults often report a subjective sense of restlessness, fidgetiness, or subtler signs of physical restlessness, such as bouncing their legs, playing with things with their hands, excessive or impulsive speech, and impulsive spending. Many adults with ADHD report what they describe as “mental hyperactivity,” such as having their train of thought easily disrupted by new thoughts or ideas. These various 8 Adult ADHD internal distractions continue to create functional difficulties for affected individuals, tax- ing already weakened motivation for and follow-through on tasks. These difficulties interfere with academic functioning, occupational performance, interpersonal relationships, and even recreational pursuits. Furthermore, adults with the hyperactive-impulsive or combined presentations have an elevated risk for substance abuse, cigarette smoking, driving problems, and oppositional or antisocial behaviors that could result in later health, interpersonal, and legal problems (Barkley, 2006, Barkley et al., 2008; Galéra et al., 2012; Klein et al., 2012; Satterfield et al., 2007; Weiss & Hechtman, 1993; Wilens et al., 2002). As could be discerned from the description above, mental restlessness would likely be distracting and various other facets of hyperactivity/impulsivity will interfere with concentration. What is more, it is rare that hyperactivity/impulsivity exists without features of inattention. The next section will focus on the inattentive symptoms of ADHD.

ADHD, Predominantly Inattentive Presentation About 20–30% of all individuals with ADHD exhibit the predominantly inattentive presentation (Wilens et al., 2002; Wilens et al., 2009). Even in cases of a combined presentation, it is often the inattentive symptoms that are associated with the impairments that lead adults to seek assessment and treatment. In fact, although adults with ADHD may report having encountered seemingly “new” difficulties or impairments as school became more difficult and required better executive functioning, the presence of inattentive symptoms often predates these functional difficulties. Most adults with ADHD provide accounts of having been able to adapt to the demands of school, though often by using inefficient and unsustainable strategies, such as spending inordinate time on assignments or simply being able to get by without completing them. Thorough assessment often reveals that there has been supportive “scaffolding” throughout the developmental course that allowed the child to function adequately, if not well, in school, such as time in class or during a long bus ride to work on assignments or parental supervision (or intervention) to ensure homework completion. As the requirements for self-organization, self-motivation, and time and effort management increase in later grades and in adult life, so too do the effects of long simmering ADHD. Thus, even if the patient performed well in school as a child or teen and kept up with work, it is important to explore how these outcomes were achieved in terms of developmentally appropriate expectations. Most individuals described “getting by” by using strategies that do not work in adult life.

Downloaded by [New York University] at 12:14 14 August 2016 Adults with ADHD have disproportionate trouble resisting the lure of distracters that offer immediate positive reinforcement (e.g., something enjoyable) or negative reinforcement (e.g., escaping a less compelling or distasteful task before them), or a combination. In such cases, an individual with ADHD is prone to seek activities that are more immediately reinforcing and more pleasurable than to be vigilant about less exciting, though ultimately more important, tasks. Further, once interrupted, individuals with ADHD have greater difficulty than non-ADHD individuals reengaging in an activity. Thus, they have greater difficulty initiating, persisting with, and working to completion on tasks that are not intrinsically appealing to them to a degree that is impairing. Symptoms of distractibility and poor sustained attention remain relatively constant across the lifespan for individuals with ADHD, though they tend to play a greater role in Adult ADHD 9 the presenting problems cited by adults (Wilens et al., 2002; Wilens et al., 2009). The demands on concentration, organization, and time management skills increase in adulthood, and the negative consequences associated with inattentiveness and disorganization become more severe. Hence, even though symptom severity might remain stable, the contextual demands for good attention increase, thus creating greater impairment from the same symptoms. As an example, a the driver of a car stuck moving at 25 mph and weaving from side-to-side on a deserted country road will not necessarily cause a problem; however, when the same car enters a crowded interstate highway with a posted speed limit of 65 mph, there is risk for serious problems—driving demands have esca- lated but the driver cannot adjust to the new context. The situation is similar for individuals with ADHD who have benefitted from compensations when they were younger but now face the more challenging demands of adult life. Self-reports of adults and corroboration from others who know them (e.g., parents, spouses, roommates) confirm that ADHD patients are likely to report greater numbers of symptoms of inattention than controls (Barkley et al., 2002; Barkley et al., 2008). In addition to the DSM symptoms, adults with ADHD describe problems such as “losing things,” “appearing spacey or in a daydream,” “having difficulty getting started on and finishing tasks,” and “being easily distracted by interruptions and things that have nothing to do with the task at hand,” among many other complaints. On the other hand, discussions of attention and distraction in ADHD often include the notion of hyperfocus. Hyperfocus is often described by adults with ADHD as the ability to become engaged, if not overly immersed, in a task for an extended time. Individuals will report the ability to read a substantial portion of a book late into an evening, make notable progress on a written report in one sitting, or tackle a variety of household chores during a day, but not be able to sustain consistent performance of these tasks across time. Hyperfocus has been romanticized in discussions of ADHD as a beneficial trait, but it is difficult to define the merits of a behavior outside of the context in which it is performed. The ability to complete a report or cram for an exam at the last minute may be adaptive inasmuch as it allows the individual to perform an isolated task. However, reli- ance on hyperfocus often represents the end stage of a cycle of inefficient coping. Indi- viduals rely on “brinksmanship” when facing a deadline at the cost of the quality of the final product and personal well-being. Indeed, hyperfocus may better be understood as a form of perseveration, or the inability to disengage from one behavior and switch to another. Said differently, ADHD is not really an “attention deficit” disorder but rather an “attention allocation” or “modu-

Downloaded by [New York University] at 12:14 14 August 2016 lation” disorder. Thus, an adult with ADHD, once engaged in a task, is likely to keep going in that task rather than switch to doing something else. In many cases the task may be viewed in the short term as being productive (e.g., “I’m organizing the clutter on my desk.”), but it likely is a distraction from a higher-priority task (e.g., “I organized my desk but never worked on the report for work.”), a phenomena we have deemed “pseudoefficiency,” or what patients have described as “being busy all day but not completing any priority tasks.” Unlike predominantly hyperactive/impulsive or combined presentations, adults with the predominantly inattentive presentation often do not report many disruptive behavioral problems at home or at school when they were younger (Wilens et al., 2009). Rather, inattentive adults were likely to have experienced academic problems and received 10 Adult ADHD feedback from teachers noting their need for more supervision in completing work, the need to pay better attention in class, to develop better study skills, and often the notion that the students “underperformed” relative to their abilities. Their grades likely suffered from turning in assignments late, incomplete, or forgetting to turn them in altogether. Because their difficulties generally were internalized (e.g., Nigg, 2006; Tannock, 2000) and did not lead to disruptive behaviors that would capture the attention of teachers, these patients’ difficulties often were not identified until college or later in adulthood. In addition to the predominantly inattentive presentation, persons with the combined presentation also experience many of these same difficulties. In fact, even individuals with a preponderance of inattentive symptoms often report several of the hyperactive/ impulsive symptoms, what could be considered “subthreshold combined presentation” more than a purely inattentive presentation (Roberts & Milich, 2013). The most common presentation of ADHD is the combined presentation, which is discussed next.

ADHD, Combined Presentation The combined presentation is the most frequently encountered subtype of ADHD in clinical settings, affecting about 50–75% of all individuals with ADHD (Nigg, 2006; Wilens et al., 2002). These individuals experience a full complement of both inattentive and hyperactive-impulsive symptoms, creating a double whammy of symptomatic difficulties. Considering the distinct risk factors associated with externalizing behaviors, individuals in this category are often lumped together with those fulfilling diagnostic criteria for the predominantly hyperactive-impulsive presentation, though some argument can be made about how to conceptualize the distinction better. Regardless, individuals with the combined presentation tend to be the most impaired of the ADHD presentations (Barkley, 2006; Wilens et al., 2002). The inattentive symptoms are comprised of issues that overlap with the executive function categories of organization, time management, and motivation, which are skills that are increasingly relevant for adults. Moreover, in addition to managing personal affairs, adults are more likely to have responsibilities and obligations that have effects on others, such as employers and coworkers, romantic partners, and family and children. Children, adolescents, and young adults who are in school follow an academic calendar during which there are discrete end points for a semester and school year before starting anew at the beginning of the next cycle. Adult obligations, on the other hand, such as parenting, managing relationships, workplace performance, and tracking various affairs

Downloaded by [New York University] at 12:14 14 August 2016 of daily living are ongoing, cumulative across time, and have no end point. Hence, ADHD and executive dysfunction have uniquely problematic and potentially intensify- ing effects in adult life. The hyperactive-impulsive domain of symptoms generally overlaps with the executive function domains of emotional regulation and self-restraint (i.e., impulse control), creating significant problems for many adults with ADHD. In particular, expressions of anger and rash decisions can impair personal relationships and are often the source of job termi- nations more so than performance inefficiencies, such as disorganization (Barkley et al., 2008). Reckless spending, impetuous statements (e.g., “saying the wrong thing”), and impulsive compliance—agreeing to tasks and obligations before assessing one’s ability to complete them—are among the coping difficulties experienced by adults with ADHD. Adult ADHD 11 From a diagnostic and conceptual standpoint, the question may be asked as to the correct presentation diagnosis for individuals who exhibited symptoms consistent with the combined presentation in childhood but who present in adulthood with complaints related to inattentive features? In general, it seems that the “once combined presentation, always combined presentation” guideline is useful, akin to the subthreshold combined presentation mentioned earlier. That is, the decrease in overt signs of motoric hyperactivity and impulsivity does not necessarily indicate that these features have remitted but that they simply manifest themselves differently. These changes might also result from improved coping if not improved self-control, or from “niche selection” (i.e., choosing situations that are less demanding or that provide compensatory support). Functional analyses of problematic situations for adults with a history of the combined presentation often reveals subtle examples of restlessness or impulsivity that contribute to ongoing functional difficulties that make a distinct contribution to complaints of disorganization, procrastination, and distractibility. Of course, this observation makes sense when using an executive dysfunction model for understanding ADHD that considers these difficulties in the context of the gamut of executive function domains in order to discern a patient’s ADHD profile.

Other Specified ADHD and Unspecified ADHD These final presentation categories reflect persons who, although their symptom profiles do not fulfill diagnostic criteria, seek help for significant functional difficulties related to limited, subthreshold symptom profiles consistent with ADHD that are not better explained by another syndrome. These categories replace the ADHD, Not Otherwise Specified (NOS) category in DSM-IV. The Other Specified diagnosis is used when a patient presents with features of ADHD that do not meet full criteria and the evaluator chooses to communicate the reason full criteria have not been met, such as insufficient numbers of symptoms or onset of symptoms before adulthood cannot reliably be established. The unspecified category is used for similar situations in which the evaluator does not provide a reason the diagnostic criteria have not been met. The ADHD, NOS category had been used to document residual symptoms of ADHD in someone whose symptoms had formerly met full diagnostic criteria. DSM-5 provides the “in partial remission” specification for this purpose. Regardless, for the vast majority of individuals for whom these residual diagnostic

Downloaded by [New York University] at 12:14 14 August 2016 categories apply, there are usually ongoing functional problems associated with ADHD- type symptoms, albeit not reaching the threshold for a full diagnosis of ADHD. Thus, subthreshold symptoms can still create difficulties in functioning for which some manner of clinical intervention is appropriate.

Sluggish Cognitive Tempo/Concentration Deficit Disorder Although not included in DSM-5, there is a growing literature on the difficulties encountered by and unique treatment needs of individuals with Sluggish Cognitive Tempo (SCT) that might be better described as Concentration Deficit Disorder (CDD). In clinical practice, many individuals with ADHD for whom inattentive symptoms predominate 12 Adult ADHD will usually exhibit many subthreshold features of hyperactivity/impulsivity (Bauermeister, Barkley, Bauermeister, Martinez, & McBurnett, 2011). Adults with SCT/CDD, on the other hand, represent a subset of individuals who exhibit features of a pure manifestation of the inattentive type of ADHD with few, if any, coexisting features of hyperactivity/impulsivity, though evidence indicates that SCT/CDD is distinct from ADHD (Barkley, 2012a). The classic presentation of ADHD involves features of high distractibility and poor attention vigilance, which can be considered as examples of attention and sustained concentration being engaged but then punctuated or interrupted. In contrast, SCT/CDD is characterized by difficulties orienting and engaging attention, effort, and alertness in the first place. Individuals with SCT/CDD exhibit difficulties associated with being day- dreamy, sleepy (particularly with boring tasks), lethargic, and sluggish, the first two descriptors being the most distinctive factors of SCT/CDD (Penny, Wachbusch, Klein, Corkum, & Eskes, 2009). Hypoactivity is commonly observed, with individuals with SCT/CDD encountering difficulties getting and staying engaged in tasks and activities. Anxiety and social withdrawal also are prevalent among individuals with SCT/CDD along with a notable lack of externalizing behaviors. Moreover, executive dysfunction is less prevalent among individuals with SCT/CDD than is typically seen in ADHD (Bauermeister et al., 2011). SCT/CDD creates comparable levels of impairment as those seen in traditional ADHD symptoms. A study of children with ADHD indicated that while inattention pre- dominates as the defining characteristic of ADHD and the main source of impairments, SCT/CDD emerged with hyperactivity/impulsivity as distinct sources of symptomatol- ogy and impairment (Bauermeister et al., 2011). A study of adults showed that SCT/ CDD is distinct factor from ADHD (though there is substantial overlap) and that it is associated with impairments, either when it presents alone or in combination with ADHD (Barkley, 2012a). The accurate identification of SCT/CDD has treatment implications. The symptoms of SCT/CDD do not seem to respond to ADHD medications, at least not to the psychostimulants. Better results are obtained with atomoxetine or antidepressants typically used to treat anxiety. Moreover, there have been encouraging findings from studies of psychosocial treatments for SCT/CDD (Barkley, 2006, Pfiffner et al., 2007). Research of the diagnosis and treatment of SCT/CDD will be a fruitful field of study in the coming years with important clinical implications.

Persistence and Prevalence of Adult ADHD Downloaded by [New York University] at 12:14 14 August 2016 Many of the difficulties involved in establishing diagnostic criteria for ADHD also hinder efforts to accurately gauge the prevalence of ADHD—it is difficult to count something if it is difficult to agree upon what is being counted. The diagnostic prevalence for ADHD most often cited is 5% of the children and 2.5% of adults, derived from expert consensus from a review of the literature (APA, 2013). Published studies estimate upwards of 10% of boys and 5% of girls of elementary school age fulfilling criteria (Cen- ters for Disease Control and Prevention, 2010; Faraone, 2005). The international prevalence of childhood ADHD is estimated at 6.5% (Polancyk, Silva de Lima, Horta, Biederman, & Rohde, 2007). Some studies report even higher prevalence figures when relying on symptom checklists as the sole means to establish the diagnosis instead of a Adult ADHD 13 full clinical evaluation, with these statistics reflecting “screening” prevalence of ADHD (Nigg, 2006). A recent review of diagnostic trends over the past decade used parent reports of whether a healthcare provider made a diagnosis of ADHD and whether it was treated with medications (Visser et al., 2014). By 2011, 11% of children and adolescents in the United States had ever been diagnosed with ADHD by a healthcare professional. Of these, 83% were reported as currently having ADHD, and 69% of these current ADHD children were taking prescribed medications. These current percentages reflect a 42% increase of the diagnosis since 2003 and a 28% increase of medication treatment among currently diagnosed children since 2007. There is corroborative empirical support for the prevalence figures used in the DSM-5, though they may be a little conservative, with similar results found in international samples (3.4%) as in a US sample (4.4%), indicating that ADHD is not simply an American phenomenon that results from a fast-paced, media- and technology-saturated 21st century culture (Fayyad et al., 2007; Kessler et al., 2006). However, there is variability in international prevalence rates depending upon how ADHD is operationally defined and on how symptoms are measured and cultural differences in disclosing symptoms (Asherson et al., 2012; Gingerich, Turnock, Litfin, & Rosén, 1998). Another limitation of previous research on the persistence and prevalence of ADHD is that it has generally focused on children and, even more so, clinic-referred boys with the combined subtype, presumably exhibiting acting-out behaviors. Recent research involving community samples of children has revealed that the prevalence and severity of ADHD in both boys and girls is more similar than was previously thought (Biederman, Petty, Monuteaux et al., 2010; Miller, Ho, & Hinshaw, 2012). Studies of adults have produced similar results indicating fewer gender differences in symptom endorsement and impairments than was previously thought (Biederman, Faraone, Monuteaux, Bober, & Cadogen, 2004; DuPaul et al., 2001; Fedele, Lefler, Hartung, & Canu, 2012). Barkley (2006) summarized prevalence studies of ADHD that employed established diagnostic criteria (DSM) in US samples. The prevalence rates ranged from 2.2% to 12% of children and adolescents in the United States when using DSM-III (APA, 1980) criteria (average 4.9%); 1.4% to 13.3% when using adult ratings of DSM-III-R (APA, 1987); and 7.4% to 9.9% when using DSM-IV (APA, 1994) criteria. Nigg (2006) reported a 6.8% median estimate of prevalence from his review of five studies utilizing structured behavior ratings and assessment of impairment using DSM-IV criteria, almost equally

Downloaded by [New York University] at 12:14 14 August 2016 divided between the combined and primarily inattentive subtypes. Longitudinal studies tracking children diagnosed with ADHD into adulthood vary with regard to their use of DSM criteria, other measures of ADHD symptoms, and whether the presence of the diagnosis in adulthood is defined as meeting full diagnostic criteria, partial criteria, or as residual symptoms requiring treatment (Faraone et al., 2006). In most long-term follow-up studies, the official diagnostic criteria changed by the time children with ADHD reached adulthood, which will be an unavoidable fact for some cohorts. A well-designed national comorbidity survey revealed that 36.3% respondents who had met DSM-IV (APA, 1994) criteria for ADHD in childhood continued to meet full diagnostic criteria in adulthood, both time points measured by self-report symptoms questionnaires (Kessler, Adler, Barkley, et al., 2005). The authors noted that this is a 14 Adult ADHD conservative percentage because several DSM symptoms do not translate well for adults continuing to struggle with ADHD, resulting in an underestimation of adult ADHD. A review of numerous follow-up studies of children with ADHD indicated that the persistence rates of ADHD into adulthood depend upon the definition of persistence used (Faraone et al., 2006). When full DSM diagnostic criteria in adulthood were used as the marker for persistence, rates fell to as low as 4%. On the other hand, when using a definition of “partial remission” to reflect ongoing and clinically relevant symptoms of ADHD, persistence rates ranged from 36% to 86%. Similarly, Biederman, Mick, and Faraone (2000) reported about 40% syndromatic persistence (i.e., meeting full diagnostic criteria) among a sample of young adults (18 to 20 years) who were reassessed after having been diagnosed with ADHD in childhood. However, when defining persistence in functional terms (i.e., at least five DSM symptoms and a rating of at least moderate impairment), there was 90% symptomatic persistence among this same sample of young adults that might require clinical attention. Another issue affecting persistence rates is the reliability of self-report of symptoms by adults with ADHD. Although there are concerns about malingering and faking bad to obtain medications, services, and other secondary gains, which is an important concern in clinical practice (e.g., Harrison, Edwards, & Parker, 2007; Marshall et al., 2010), an equal concern is the under reporting of symptoms and impairments by individuals who could benefit from treatment. In a study of the persistence of symptoms in children with hyperactivity tracked into young adulthood, very low persistence rates were obtained when using subject self-report of DSM symptoms applied to existing diagnostic thresholds (Barkley et al., 2002). When adjusting the definition of persistence to a statistical threshold of self-report of symptoms that fell two standard deviations above the mean (e.g., top 7%) of a normative sample, the same responses by the subjects resulted in increased persistence. Moreover, using parents’ ratings of symptoms resulted in a jump to 66% persistence, with parental ratings having the strongest correlations with measures of impairments. There have been many other studies examining the persistence of ADHD from childhood to adulthood. Although there are differences across studies in the definition of persistence and types of assessments used, it is generally found that ADHD persists into adulthood for at least 50% of childhood cases, though the persistence of residual symptoms causing some form of functional impairment more often falls in the range of 65% to 75% (Barkley et al., 2008; Biederman, Petty, Clarke, Lomedico, & Faraone, 2011; Biederman, Petty, Evans, Small, & Faraone, 2010; Mannuzza & Klein, 1999; Weiss &

Downloaded by [New York University] at 12:14 14 August 2016 Hechtman, 1993; Wilens et al., 2002). The National Comorbidity Survey-Replication established a prevalence rate of 4.4% prevalence among US adults (Kessler et al., 2006), with a 4.2% prevalence rate among a subsample of adults in the workforce (Kessler, Adler, Ames, et al., 2005). Taken together, the prevalence rates translate to about 8 to 10 million adults being affected by ADHD in the United States. An international survey conducted in the Americas, Europe, and the Middle East similar in format to the National Comorbidity Survey found a prevalence rate for adult ADHD of 3.4%, ranging from 1.2% to 7.3% (Fayyad et al., 2007). A survey of college students found a prevalence of ADHD ranging from 0% to 8.1% in students from the United States, Italy, and New Zealand (DuPaul et al., 2001), with rates for male and Adult ADHD 15 female US students reported as 2.9% and 3.9%, respectively. Studies of adult ADHD in China, Mexico, South Africa, and other international samples indicate that the symptoms and impairments of ADHD are not limited to particular countries or cultures (Mahomedy, van der Westhuizen,van der Linde, & Coetsee, 2007; Montes, Garcia, & Ricardo-Garcell, 2007; Norvilitis, Ingersoll, Zhang, & Jia, 2008). There may be other populations in which the prevalence and effects of ADHD have not yet been well documented such as in older adults (Michielsen et al., 2012) or minority groups in the United States (Waite & Ramsay, 2010). There are underserved adults with ADHD who are in substance use treatment programs (Huntley et al., 2012; van Emmerik-van Oortmerssen et al., 2012) or in the criminal justice system (Appelbaum, 2008; Ginsberg, Hirvikoski, & Lindefors, 2010; Young et al., 2011) for whom adequate assessment and treatment might lead to decreased relapse and recidivism rates (Lichtenstein et al., 2012). A complicating factor in recognizing and getting treatment for adult ADHD is the fact that the typical features of ADHD very often coexist with other problems that may mask the symptoms of ADHD. The next section discusses some common comorbid problems observed in adults with ADHD and the many negative life outcomes they experience that make clear ADHD is a potentially disabling syndrome for which many will require treatment.

Psychiatric Comorbidity and Adult ADHD By the time children with undiagnosed or untreated ADHD reach adulthood and seek treatment, it is unusual for ADHD to be cited as the sole or even the primary reason for seeking help. It is estimated that 70–75% of adults with ADHD who enter treatment carry at least one additional psychiatric diagnosis (Barbaresi et al., 2013; Barkley et al., 2008; Biederman, 2004; Biederman et al. 2012; Brook, Brook, Zhang, Seltzer, & Finch, 2013; Kessler, Adler, Barkley et al., 2005; Kessler et al., 2006; Klein et al., 2012). The prevalence rates for anxiety disorders and depression among clinic-referred adults with ADHD are comparable to those seen in children with ADHD and occur more frequently than would be predicted by chance (Barkley, 2006; Barkley et al., 2008; Biederman et al., 2006, 2010; Kessler et al., 2006). The prevalence of substance use disorders among patients with ADHD is twice that found in the general population, with 32–53% reporting alcohol use problems and 8–32% reporting other substance use problems (Barkley, 2006; Huntley et al., 2012; McGough et al., 2005; van Emmerik-van Oort-

Downloaded by [New York University] at 12:14 14 August 2016 merssen et al., 2012). Tobacco, alcohol, and marijuana are the main substances of abuse for individuals with ADHD (Upadhyaya & Carpenter, 2008). Although the findings of comorbidity within samples of adults with ADHD are not surprising to clinicians familiar with ADHD, many clinicians do not have experience with ADHD. Hence, it is important to consider that many individuals may initially seek treatment for other problems, with ADHD issues identified only later in treatment (if at all). Thus, the study of “reverse comorbidity” of ADHD (Wilens, 2007) in research on other disorders is particularly relevant. Alpert et al. (1996) assessed a sample of patients in treatment for depression and found that 16% had a history of significant symptoms of ADHD in childhood, with 12% of the sample reporting persistent difficulties related to these symptoms in adulthood. Kessler et al. (2006) found that the prevalence of 16 Adult ADHD ADHD in US adults with major depression is 9.4% and among adults with dysthymia, 22.6% have coexisting ADHD. Clinical interviews conducted with nonpsychotic adult outpatients and healthy community controls in treatment in a Mexican clinic revealed prevalence rates for ADHD of 16.8% and 5.37%, respectively (Montes et al., 2007). The severity of psychopathology among these outpatients with ADHD was higher than for outpatients without ADHD. Nearly 10% of a large sample of adult patients in treatment for bipolar disorder reported a lifetime prevalence of ADHD (Nierenberg et al., 2005). Individuals with a bipolar disorder-ADHD combination commonly endorse symptom profiles indicating earlier onset of mood problems, shorter periods of wellness, more depressive periods, and more psychiatric comorbidity than individuals with bipolar disorder alone (Karaahmet et al., 2013; Klassen, Katzman, & Chokka, 2010; Nierenberg et al., 2005). Reviews of insurance claims have been used to assess the effect of a diagnosis of adult ADHD on direct medical costs, comorbidities, and workplace costs (i.e., missed work, short-term disability) compared with a non-ADHD sample (Birnbaum et al. 2005; Secnik, Swensen, & Lage, 2005), resulting in $31.6 billion in excess costs compared with non-ADHD controls. Findings from reviews of these databases indicate that adults with ADHD are more likely to have coexisting diagnoses of anxiety, depression, bipolar disorder, substance use disorders, oppositional defiant disorder, antisocial personality as well as asthma, than are controls (Secnik et al., 2005). When controlling for comborbi- ties, adult ADHD is associated with double the costs for outpatient treatment, inpatient treatment, prescription drugs, and overall medical care than for controls. Taken together, these findings suggest that comorbidity in the assessment and treatment of ADHD is the rule rather than the exception. This fact makes assessing ADHD symptoms difficult, as it is often tricky to discern whether complaints of inattention or disorganization reflect the chronic and pervasive symptoms of ADHD, result from another disorder, or some combination of the two. In addition to psychiatric comorbidity, adults with ADHD are at higher risk for a number of serious life problems that affect their ability to function. In fact, it is often the impairments in these life domains and adult roles that lead individuals to seek assessment and treatment. The next section reviews the life outcomes of adults with ADHD.

Life Outcomes of Adults With ADHD It is clear that a lifetime history of ADHD is associated with greater likelihood of exhibiting

Downloaded by [New York University] at 12:14 14 August 2016 impairments in at least one major domain of functioning. When compared to adults without ADHD, adults with ADHD consistently complete fewer years of school, have lower levels of employment, earn lower salaries, change jobs more frequently, receive more negative ratings of work performance, have higher rates of marital discord (if not greater divorce rates), lower relationship satisfaction, higher risk for psychiatric and substance abuse problems, have higher rates of pessimism, lower life satisfaction, and are more likely to report impairment that interferes with keeping up with the demands of daily life (Bar- baresi et al., 2013; Barkley et al., 2008; Biederman et al., 2006; Galéra et al. 2012; Klein et al., 2012; Nigg, 2013; Rasmussen & Gillberg, 2000; Weiss & Hechtman, 1993). Not surprisingly, a consistent finding across studies is that adult ADHD has a negative impact on identity, satisfaction, life options, and self-esteem (Harpin, Mazzone, Raynaud, Adult ADHD 17 Kahle, & Hodgkins, 2013). When compared with non-ADHD controls, adults with ADHD who were asked to recall their experiences in childhood and adolescence rated themselves as less likely to be engaged in most academic, extracurricular, social, and family activities (Biederman et al., 2006). Of adults with ADHD, 72% said their symptoms have had a lifelong impact and they were significantly more likely than controls to report workplace and relationship impairment. Not surprisingly, adults with ADHD were significantly more negative in their outlooks on life and had lower ratings of self-acceptance. Adults with ADHD were less likely to be employed regardless of academic attainment and had lower household incomes than matched controls (Biederman & Faraone, 2006). In fact, assuming that the reported differences in educational attainment and achievement are fully attributable to ADHD symptoms, the estimated annual individual income loss associated with a diagnosis of ADHD was estimated at upwards of $10,300 to $15,400 per person, which reflects a total annual income loss of $67 to $116 billion associated with a diagnosis of ADHD. In addition to lost income due to lower education attainment, ADHD is associated with lower levels of workplace performance (Kessler, Adler, Ames, et al., 2005). In a survey of US workers, ADHD emerged as a significant predictor of overall lost work performance. More specifically, ADHD was associated with 13.6 days of absenteeism (missed days of work) and 21.6 days of presenteeism (underperformance on the job), which totals 7 work weeks of lost productivity at an annual salary-equivalent loss of $5,661 per worker with ADHD. The projected impact on the US labor force is estimated to be 120.8 million lost workdays per year at a salary-equivalent cost of $19.6 billion. Other longitudinal and cross-sectional studies have revealed similar patterns of lower academic and vocational achievement, more frequent job changes, poorer driving records, higher rates of divorce, higher healthcare costs (even when controlling for psychiatric care), and greater risk for developing substance abuse and psychiatric disorders among adults with ADHD, when compared with non-ADHD controls (Barbaresi et al., 2013; Barkley, 2006; Barkley et al., 2008; Brook et al., 2013; Galéra et al. 2012; Klein et al., 2012; Weiss & Hechtman, 1993), including preliminary findings of increased risk for suicide (Barbaresi et al., 2013). Surveys of workers with ADHD indicate that they earn lower salaries, have lower work performance, and higher rates of conflict and disciplinary actions when compared with both clinical and community control groups (Barkley et al., 2008; Barkley & Murphy, 2010). Moreover, adults with ADHD are more likely than controls to report being un- or underemployed or in the process of seeking work (regardless of academic attainment) in

Downloaded by [New York University] at 12:14 14 August 2016 addition to being less productive on the job and having more frequent job changes (Bark- ley et al., 2008; Biederman et al., 2006; Kessler, Adler, Ames, et al., 2005). Laboratory studies of workplace behavior also reveal various difficulties encountered by workers with ADHD in managing the demands of an office (Fried et al., 2012). Adult ADHD also accounts for a significant percentage of individuals on leave from work due to “burnout” (Brattberg, 2006) or disability (Mordre, Groholt, Sandstad, & Myhre, 2012). Evidence is mounting that ADHD is an important public health issue. When considering ADHD and, more specifically, executive dysfunction as reflecting difficulties with organizing behavior across time, it stands to reason that these difficulties with self- control would also lead to long range problems for physical health and well-being (Nigg, 2013). In fact, longitudinal and cross-sectional studies of adults with ADHD suggest a 18 Adult ADHD pattern of poor health behaviors (e.g., nicotine use, substance use, sedentary lifestyle, poor diet, etc.) that predicts various health risks later in life (Barkley et al., 2008), including obesity (Altfas, 2002; Cortese, Faraone, Bernardi, Wang, & Blanco, 2013). Regarding financial “health” and stability, adults with ADHD are less likely than controls to save money, have a retirement fund, and to resist impulse purchases (Kaufman-Scarborough & Cohen, 2004), and were more likely to experience problems related to nonpayment of bills (e.g., utilities turned off) (Barkley, Murphy, O’Connell, Anderson, & Conner, 2006; Barkley et al., 2008). A longitudinal study of children with ADHD followed into young adulthood revealed that adolescents with ADHD began having sex at an earlier age and were less likely to use contraception when compared with non-ADHD peers. Not surprisingly, the ADHD group had four times the rate of sexually transmitted disease and almost ten times the pregnancy rate by age 20 when compared with the non-ADHD group (Barkley et al., 2008). There have been other studies documenting risky sexual behavior among young adults with ADHD (Flory, Molina, Pelham, Gnagy, & Smith, 2006). There is also a solid foundation of research showing that automobile drivers with untreated ADHD exhibit poorer driving behaviors than do drivers without ADHD, based on reviews of personal driving records and performance on driving simulation tasks. The results indicate that ADHD drivers have a greater number of driver-caused accidents, and on average, these accidents are more severe, including physical injury. Drivers with ADHD also exhibit more unsafe driving behaviors (e.g., speeding) and incur moving violations more than non-ADHD drivers (Barkley & Cox, 2007; Barkley et al., 2008; Fried et al., 2006; Thompson, Molina, Pelham, & Gnagy, 2007). Of note, the driving performance of ADHD drivers who have not taken their medication is equal to that of drivers who would be considered legally intoxicated (Barkley et al., 2006; Weafer, Camarillo, Fillmore, Milich, & Marczinski, 2008). To this point, we have discussed the diagnostic criteria, developmental course, and prevalence of ADHD in addition to the common comorbidities and life outcomes experiences by adults with the disorder. The next section will provide a brief overview of research on the multiple domains of the etiology of ADHD, including the executive dysfunction model of ADHD to which we have already referred.

Etiologic Models for ADHD ADHD has strong genetic and neurobiological underpinnings. Research into the herita-

Downloaded by [New York University] at 12:14 14 August 2016 bility of ADHD symptoms has focused on its prevalence in biological relatives, identical and fraternal twins, and in adoptive families (with no genetic similarities). The findings consistently point to ADHD as being a highly heritable condition, with close to 80% of the variance of the traits associated with ADHD resulting from genetic factors, which is similar to the heritability of height/stature. Similarly, neuroimaging studies of brain structure and function have revealed differences between the development and functioning of the brains of individuals with and without ADHD. Studies have aimed at localizing functioning and, more specifically dysfunction, in order to help explain the underpinnings of ADHD. We will begin with a review of the executive dysfunction model of ADHD, which we find to be a useful framework for assessment and treatment planning. The research on Adult ADHD 19 genetics, structural and functional neuroimaging, and other neurobiologically informed models for understanding ADHD will also be discussed. Rather than finding a single root cause for the disorder, the extant and future research will likely produce inclusive brain models of ADHD characterized by the interplay of different neural systems and by gene x environment interactions influencing the developmental course of ADHD (Cas- tellanos & Proal, 2012).

Executive Dysfunction Model of ADHD We have been using the executive function framework to understand ADHD throughout the book thus far and will now provide a more extensive review based largely on the work of Barkley (1997, 2001, 2011b, 2012b). A concise definition of executive functions is “those self-directed actions of the individual that are being used to self-regulate” (p. 56, Barkley, 1997). To elaborate on this definition, executive functions represent “the use of self-directed actions so as to choose goals and to select, enact, and sustain actions across time toward those goals usually in the context of others often relying on social and cultural means for the maximization of one’s longer-term welfare as the person defines that to be” (p. 176, Barkley, 2012b). Hence, the executive functions represent the self- regulation of behavior inasmuch as they promote one’s ability to pursue a distant goal by implementing the necessary action plans to achieve the goal despite a delay in achieving the ultimate reward. As can be imagined, there are a number of coordinated behaviors involved in such a process and various metaphors have been employed to explain the organizing role of the executive functions: central executive, coach, conductor, organizer, director, general manager, and CEO (Brown, 2013). Barkley (1997, 2012b) has elaborated on an elegant model of executive functions and ADHD. We will provide a brief summary, though interested readers are directed to the cited works for more detailed information, research evidence, and implications of the executive functions beyond their role in ADHD. The executive dysfunction model also provides targets for treatments, including medications and psychosocial intervention (Brown, 2013; Ramsay, 2010a, 2010b; Solanto, 2011). Executive functions are self-directed actions used by individuals to self-regulate or self-manage in order to adapt to and handle environmental demands (Barkley, 1997). There is a developmental sequence of emergence of the executive functions, with successive self-directed behaviors building upon the existing foundation forged by those pre- ceding them; thus, they function individually but most importantly collectively.

Downloaded by [New York University] at 12:14 14 August 2016 A foundational executive function involves the capacity for self-directed attention, which allows for self-awareness and self-monitoring. This initial capacity allows an individual to be aware of himself or herself, actions, and personal interests, setting the stage for behavioral inhibition. In addition to being able to inhibit a natural response to a situation, this restraint also represents the capacity to interrupt and disengage from an ongoing behavior, and to resist interference from competing demands on attention and effort. In effect, behavioral inhibition allows individuals to hit a pause button in order to transcend the in-the-moment experience to consider how to act (i.e., “Don’t just do something, sit there”). The capacity for behavioral inhibition provides the necessary space in time, experience, and action to utilize the subsequent executive functions that emerge in a step-wise 20 Adult ADHD manner over the course of development. What is more, each executive function itself undergoes a transformation by which an overt behavior becomes increasingly self- directed and eventually is privatized and fully cognitive (i.e., covert). Nonverbal working memory develops as the ability to hold and replay events in one’s mind. The process is akin to football players analyzing game film to identify ways they can improve their performance and to assess opponents’ tendencies that can be exploited during a game. Sense of time and organization of behavior across time also are associated with nonverbal working memory. The capacity for verbal working memory enables the privatization of speech or internal self-talk. What starts as the outward use of speech to describe events, grows into the use of inner speech to guide one’s own behavior, eventually becoming the capacity for developing and following rule-governed behavior, and later for gaining other skills, such as reading comprehension. Affect regulation arises with the ability to experience and recognize different emotional states. Individuals learn to manage and modify their feelings, handle uncomfortable emotions by generating corresponding soothing emotions, etc. Emotional regulation ultimately allows individuals to be able to conjure up emotional states and use them to follow through on tasks in the absence of immediate and external motivators (i.e., intrinsic motivation). This is especially important in situations requiring delayed gratification. Reconstitution emerges next and represents the ability to analyze and synthesize behaviors. These are skills central to planning, innovation, creativity, and problem solving. The childhood version of this skill manifests as externalized play, including the manipulation of the environment and imaginative role-playing, thereby figuring out how things work as well as how different people work. These skills evolve into the ability to quickly and efficiently develop plans for managing life situations and handling problems in one’s mind without having to rely on trial-and-error learning. These core executive functioning skills are nested within a larger framework of the far reaching effects of the executive functions in communal life. Drawing from the evolution-based model of the extended phenotype for understanding how various behavioral adaptations evolve (Dawkins, 1982), Barkley (2001, 2012b) has examined the executive functions as adaptations. Moreover, while being maintained through natural selection, the adaptive effects on individual survival has ripple effects into social and community functioning, with ever-widening effects across times and across distance. The executive dysfunction model of ADHD has important diagnostic and clinical

Downloaded by [New York University] at 12:14 14 August 2016 utility. Rather than looking solely for the elusive symptoms of attention, hyperactivity, or impulsivity, the executive dysfunction model provides a lens through which ADHD can be “seen” and assessed. Research on measures of executive functions has generally identified several key, semi-distinct variables: time management, organization/problem solving, self-motivation, impulse control, and emotional management. These, in turn, provide a useful conceptualization of ADHD and its manifestations in daily life. Self- report measures of the executive functions have emerged as a specific, reliable diagnostic measure of adult ADHD, although they are not yet well represented in the extant diagnostic criteria (Kessler et al., 2010). We are convinced that the executive dysfunction model of ADHD provides a scientifically sound and clinically useful model. However, there are complex genetic and Adult ADHD 21 neurological factors that are associated with the manifestations of ADHD and that are central to our understanding of the disorder. The next sections will review models for understanding the etiology of ADHD and executive dysfunction drawn from diverse research paradigms, including genetics and structural and functional neurobiology.

Genetics Findings from genetics research consistently demonstrate that shared environmental factors (i.e., social class, home environment) account for 0–6% of individual differences in ADHD symptoms; nonshared environmental factors (i.e., nongenetic factors such as neurologic injury or exposure to toxins) account for 9–20% of individual differences in ADHD symptoms; and genetic factors, on average, account for close to 80% of individual differences in ADHD symptoms (Barkley, 2006; Franke et al., 2011; Mick & Faraone, 2008; Nigg, 2006; Pliszka, 2003; Wallis, Russell, & Muenke, 2008). The gold standard of genetics research is the study of identical twins. The goal of such research is to, as much as possible, tease apart genetic and environmental contributions to the occurrence of various disorders. Identical, or monozygotic twins (MZ), develop from the same fertilized egg and, thus, share identical sets of genes. It is nature’s version of cloning. Fraternal, or dizygotic twins (DZ), develop from two separate fertilized eggs. These twins share half their genes, just as do all other two children of the same biological parents. When twins are raised together, it is presumed that each sibling in the pair has had essentially similar environmental experiences. Thus, it is predicted the MZ twins would appear to be more similar than DZ twins for genetically influenced traits or conditions. In fact, twin studies of childhood ADHD have consistently demonstrated a high heritability rate of ADHD and that genetic factors account for a substantial amount of variance for ADHD symptoms (Franke et al., 2011). Results from adoption studies, in which there is no genetic connection between children and their adoptive parents, indicate adopted children with ADHD are significantly more similar to their biological parents than they are to their adopted parents (Franke et al., 2011; Sprich, Biederman, Crawford, Mundy, & Faraone, 2000). Features of ADHD tend to cluster within families, both within generations, with increased risk of ADHD for siblings of a child with ADHD, and across generations, with increased risk of ADHD for children of an adult with ADHD and increased risk of ADHD for parents of a child with ADHD (Franke et al., 2011). Siblings of adults with ADHD also have an elevated diagnostic risk.

Downloaded by [New York University] at 12:14 14 August 2016 There are many candidate genes implicated in ADHD, most of which are associated with dopamine transporters and receptors (Franke et al., 2011). As one example of this research, alternations in the normal functioning of the dopamine transporter gene have been observed in recent neuroimaging studies of patient with ADHD (Krause, 2008). Since reuptake into the presynaptic terminal is the prime method by which the effect of dopamine is halted (Pliszka, 2003), increased activity of this gene leads to more rapid clearance of the neurotransmitter from the synapse, and hence, to functional dopamine depletion—a highly plausible explanation for at least one aspect of the pathophysiology of ADHD. Finally, a study of gene and environment interactions in ADHD provides a reminder of the complexity of ADHD genetics as well as of the study of genetics, in general 22 Adult ADHD (Neuman et al., 2007). The presence of two genetic polymorphisms implicated in ADHD (DAT1 and DRD4) and an environmental risk factor (i.e., exposure to maternal smoking in utero) were studied in terms of the relative risk for ADHD in a sample of twin pairs of children. While each of the individual risk factors were associated with significantly increased risk for ADHD (ranging from 2.6 to 3.0 times greater risk), the combination of the three risk factors resulted in risk for ADHD 9 times greater than those without risk. Thus, there is an important interaction between genetics and environment. The next section starts the review of the various neurobiological systems that genetics influence, and that affect the interaction individuals with ADHD have with their environments.

Neurobiology Neuroimaging technology has allowed researchers to study the structure and functioning of the brain with increasing specificity. The results of these studies must be approached with caution due to the small numbers of subjects from which the findings often are drawn, the inconsistency of findings across studies, and the fact that as a field we are still trying to sort out the significance of the activity versus inactivity of certain brain regions in response to different tasks. Despite these limitations, neuroimaging research is reporting consistent findings regarding the neurobiological underpinnings of ADHD (see Bush, 2010; Konrad & Eickhoff, 2010; Purper-Ouakil et al., 2011 for reviews). One important dimension of ADHD that has been increasingly explored through the use of neuroimaging is the developmental trajectory of ADHD on a neural level. Shaw et al. (2007) examined Magnetic Resonance Imaging (MRI) obtained from children at multiple points in development to determine the point at which they reached peak cortical thickness in the cerebrum, which occurs before there is a thinning during adolescence. The results indicated that on average, children with ADHD reached peak cortical thickness 3 years later than non-ADHD controls. This delay was most prominent in the prefrontal regions most often associated with ADHD symptoms and executive functions. The fact that children with ADHD followed a similar developmental trajectory as controls, eventually achieving peak cortical thickness but at a slower rate suggested that ADHD represents a delay in cortical maturation. Moreover, this developmental trajectory may explain why some children with ADHD exhibit symptomatic improvement or remission in adulthood (e.g., Barkley et al., 2008). However, this line of research also suggests that there are likely multiple trajectories associated with forms of ADHD that persist into adulthood. More recently, children with and without ADHD were compared on a measure of

Downloaded by [New York University] at 12:14 14 August 2016 the maturation of cortical surface area and gyrification (Shaw et al., 2012). MRI was obtained at multiple points in development to determine the point at which peak surface area was achieved. The non-ADHD children achieved peak cortical surface area in the right prefrontal cortex at an average age of 12.7 years as compared with 14.6 years for ADHD children, with delays observed in the frontal, temporal, and parietal regions of the brain. Most of the data (92%) were obtained from children younger than 18 years; thus there is no information on the time frame at which there is stabilization of the cortex in adulthood. This finding is of clinical interest because the fact that ADHD is associated with delays in both cortical thickness and surface area sets it apart from other disorders associated with delays in one but not both measures, such as dyslexia and autism (Shaw et al., 2012). Adult ADHD 23 There is evidence of differences in the trajectory of growth of certain regions of the brain in cases of ADHD when compared with controls and with the sizes of those regions closely associated with executive functioning. Total cerebellar and cerebellar vermis development was compared in a sample of ADHD and non-ADHD children and adolescents (Mackie et al., 2007). The ADHD group was further divided with regard to clinical functioning (i.e., better vs. worse). The ADHD group exhibited a nonprogressive loss of volume in the superior cerebellar vermis, regardless of clinical outcome. When comparing the clinical outcome groups of ADHD subjects, the worse-outcomes group exhibited a continued and progressive relative decrease in total cerebellar volume, diverging further from the normal trajectory during adolescence; the better-outcomes ADHD group exhibited a developmental trajectory parallel to the non-ADHD comparison group but still lagging behind this group (although not as far behind as the worse functioning ADHD group). It is now believed that some of the neuropsychological deficits that accompany ADHD, such as impaired motor control, inefficient procedural learning, and difficulty with multitasking, stem from cerebellar underdevelopment, with normalization of volumes in certain regions associated with clinical improvements and progressive volume loss associated with persistence of ADHD symptoms (Purper-Ouakil et al., 2011). A prospective study of male children diagnosed with ADHD who were followed 33 years later (average age 41.2 years) was conducted in which hypothesized anatomic differences were assessed through MRI obtained from the ADHD probands in adulthood (n = 59) and a comparison group of nonclinical male adults (n = 80) (Proal et al., 2011). The ADHD group exhibited overall significant reduction in average cortical thickness, with no region being thicker than those obtained from the comparison group. Differences in brain anatomy were associated with diagnostic status at follow-up in the ADHD proband group, i.e., persistent ADHD vs. remission. The persistent ADHD group exhibited cortical thinning in various posterior cortical regions, implicating neural networks associated with attention (i.e., dorsal attention network) and emotion regulation, although not in the prefrontal cortex. This finding has been further replicated by Cor- tese, Imperati et al. (2013) in a study of white matter alterations conducted on the same cohort of individuals measured at 33-year follow-up. In addition to these developmental findings, structural neuroimaging has explored the brain’s architecture in regions associated with neural processes implicated in ADHD. There have been many consistent findings of differences in the morphology of the ADHD brain when compared with nonclinical control groups, the most common finding being smaller volumes of particular prefrontal brain regions as well as global cerebral

Downloaded by [New York University] at 12:14 14 August 2016 volume (Bush, 2010). Studies using MRI to examine the brain’s morphology indicate that individuals with ADHD have right hemispheres that are somewhat smaller than those of non-ADHD controls (Pliszka, 2003). Right hemispheric reduced volume for individuals with ADHD relative to controls has also been found in cerebellum, caudate nucleus, and globus pallidus. Smaller volumes for the lateral prefrontal cortex, cingulate cortex, striatum, and corpus callosum have also been reported (Bush, 2010). Taken together, findings from structural neuroimaging studies suggest that there are subtle but definitive structural differences in some brain regions for individuals with ADHD when compared with the same brain regions of individuals without ADHD. Fur- ther, the brain regions in question play a role in regulating the types of behaviors frequently disordered in individuals with ADHD. 24 Adult ADHD In addition to structural changes, there have been differences found in the activity of diverse brain regions in individuals with ADHD. In a landmark study using Positron Emission Tomography (PET), Zametkin et al. (1990) compared rates of glucose metabolism between adults with and without ADHD. The results indicated that adults with ADHD exhibited global underactivity as measured by cerebral glucose metabolism, particularly in the attention and motor regions of the brain. Zametkin later reported results from a different PET study, which revealed that girls with ADHD exhibited global decreases in glucose metabolism when compared with non-ADHD girls, while no such difference emerged for boys with and without ADHD (cited in Pliszka, 2003). Dozens of functional neuroimaging studies have been carried out in the ensuing decade that have pursued this line of research using various functional imaging methods (see Bush, 2010 and Bush, Valera, & Seidman, 2005, for excellent reviews). By asking subjects to perform various neuropsychological tests while inside imaging machines, researchers have identified key differences in the way patients with ADHD process information and solve cognitive problems. For instance, the dorsal area of the anterior cingulate gyrus, which normally assists in the detection of error and is involved in regulating attention, motivation, response selection, and decision making, is relatively inactive in ADHD adults who are given a counting version of the Stroop test. Instead, peripheral areas are activated in the ADHD brains of subjects with ADHD, which indicate decreased task efficiency. Adolescents with ADHD activate more regions of the brain than non- ADHD subjects when asked to suppress a response on a Go-No-Go task, suggesting that this inhibiting behavior is harder and requires more work for them than for individuals without ADHD (Schulz et al., 2004).

Default Mode Network Functional Magnetic Resonance Imaging (fMRI) has been used to explore the effects of the default-mode network or “resting brain” activity (Bush, 2010; Weissman, Roberts, Visscher, & Woldorff, 2006) on attention and distractibility in individuals with ADHD. The “default mode” refers to a network of brain regions associated with task-irrelevant mental processes. In effect, when the brain is not otherwise engaged, this network engages the brain’s resting state, akin to an idling car engine. When in this mode, certain brain systems monitor the environment, physical state, current emotional functioning, mental state, mind wandering, or other task-irrelevant processes (Binder et al., 1999; Fassbender et al., 2009; Gusnard & Raichle, 2001). When called to cognitive action, these

Downloaded by [New York University] at 12:14 14 August 2016 default networks must be suppressed (i.e., inhibited) in order to allow for concentrated attention on a task, with the degree of suppression and deactivation of these networks being positively correlated with task difficulty (McKiernan, Kaufman, Kucera-Thomp- son, & Binder, 2003). Intact behavioral performance is associated with strong, negative correlations between default and control networks as well as greater intranetwork coher- ence (Castellanos & Proal, 2012). Recently, “default-mode interference” has been posited as a contributing source of distractibility and of variable reaction times in various tasks (Castellanos et al., 2008; Sonuga-Barke & Castellanos, 2007). Indeed, one of the most highly replicated findings in neuropsychologic studies of ADHD subjects is their variability of response. A parsimonious explanation for this finding is that ADHD individuals have a dys-synchrony of default mode and “on-task” mode circuits. Adult ADHD 25 Adults with ADHD have been found to have decreased connectivity between the posterior cingulate/precuneus regions and other regions associated with on-task activity, such as the dorsal anterior cingulate cortex (ACC) and the ventromedial prefrontal cortex. Young adults falling at the high end of the range of reported symptoms of ADHD (particularly features of inattention) exhibited low frequency oscillations in resting state fMRIs, which are consistent with interactions in the default attention network (De Luca, Beckmann, De Stefano, Matthews, & Smith, 2006; Helps, James, Debener, Karl, & Sonuga-Barke, 2008). A study of adolescents with ADHD reported that these teens showed greater resting-state brain activity patterns, most noticeably in the precuneus/posterior cingulate cortex region, than same-age controls (Tian et al., 2008). In particular, adolescents with ADHD exhibited greater activity in somatosensory processing regions than controls. It was hypothesized that this finding may represent an extension of the “delay aversion” commonly observed in ADHD insofar as these individuals may have difficulties maintaining a resting or “steady state,” instead attending to (and thereby distracted by) the environment or internal discomfort more so than individuals without ADHD. Find- ings from a different line of research have provided evidence that adults with ADHD require higher levels of cortical activation than controls in order to maintain sustained attention (Loo et al., 2009). Children with ADHD require a high incentive condition in order to effectively deactivate the default network (Liddle et al., 2011). Hence, individuals with ADHD may have difficulties getting their brains “in gear” unless the task at hand is particularly compelling. Although the exploration of the neural substrates of ADHD have been proposed as an alternative to the executive dysfunction model (Castellanos et al., 2008), it would seem that the aforementioned findings are consistent with difficulties related to behavioral disinhibition. That is, inhibition requires shifting into a different mode that, although not a resting state, involves cognitive activity that can be undermined by the poor interconnectivity between different functional states. The connectivity of different attention, cognitive-emotional, motivation, vigilance, and other self-regulatory systems is also of increasing interest (Bush, 2010; Konrad & Eickhoff, 2010). Eventually, it is likely that these various lines of research will converge into a more coherent model for understanding ADHD as well as other psychiatric disorders.

Dopamine Model of Motivation The role of the dopamine system and, more specifically, its role in reward reinforcement

Downloaded by [New York University] at 12:14 14 August 2016 and thereby motivation is of central relevance to understanding ADHD (Volkow et al., 2009, 2011). Dopamine dysregulation has long been implicated in ADHD, in part due to the effects on dopamine availability in the brain associated with most of the medications used to treat ADHD. Deficits in the dopamine reward system have been found to be associated with symptoms of ADHD, particularly attention deficits, along with concom- itant motivation deficits . The dopamine system plays a central though interactive role in wider-ranging reward- deficiency models of ADHD (Sonuga-Barke, 2010, 2011). Multiple neural systems interact to affect the learning experience and the developmental trajectory of individuals with ADHD. Moreover, individual learning predispositions cannot be disentangled from the environmental context in which learning occurs. A combination of deficient orientation 26 Adult ADHD to environmental reinforcement and response to reinforcement contribute to symptoms like delay aversion, impulsivity, easy boredom, temporal myopia, and temporal discount- ing. The reward-deficiency model provides various testable models at various points in the learning process (Sonuga-Barke, 2011). In addition to problems with the response to reinforcement, difficulties likely exist at the level of encoding the association of behaviors with outcomes, sorting between different coping alternatives, differential response to various outcomes (e.g., insensitivity to poor outcomes, i.e., positive bias), etc. Drawing from the studies reviewed above and others, several neurobiologically informed models of ADHD continue to be elaborated. There is an increased appreciation of the dynamic interactions of different neural systems (Bush, 2010; Sagvolden, Johansen, Aase, & Russell, 2005) as well as of the changes within and between these systems across development (Fassbender et al., 2009) that together give rise to the disorder and its variable presentation. The etiologic models described above are beginning to provide neural maps of what causes the observable symptoms of ADHD. By understanding the sources of the symptoms and their functional manifestations in daily life, it is hoped that better treatments, both pharmacological and psychosocial, can be developed. The first clinical step in the treatment process, however, is an accurate diagnostic assessment for adult ADHD, which is the focus of the next section.

Assessment of Adult ADHD In this section, we will discuss the different components of a comprehensive evaluation for adult ADHD. We have modified our diagnostic approach somewhat since the publication of the first edition of this book. While the general domains of our assessment remain the same, several new and helpful inventories have been published in the intervening years that we have incorporated into our evaluation protocol (see also Ramsay, 2014 for a review of evaluation procedures).

Phone Screen/Home Packet/Clinical and Background Questionnaires Before scheduling an individual for an evaluation, we conduct a brief phone screen to ensure that it makes sense to move ahead with the initial assessment. We administer the World Health Organization’s 6-item, Adult ADHD Symptom Rating Scale-Screener as a quick screen for ADHD, which is a subset of the larger 18-item Adult Self-Report Scale

Downloaded by [New York University] at 12:14 14 August 2016 (Adler, Kessler, & Spencer, 2003). We also inquire about other symptoms during this initial contact so as to screen for psychiatric complaints suggesting the presence of a non-ADHD condition (e.g., manic symptoms, hallucinations) or issues requiring different services (e.g., active substance dependence, suicidal behavior). Each prospective patient scheduled for an evaluation receives a “home packet” they must fill out prior to their appointment. In addition to a cover letter with the date and time of the initial appointment, directions to the office, and various administrative and consent forms, we include self- and other-report clinical inventories used in the evaluation as well as background information forms (e.g., life history, treatment history, etc.). Whenever available, patients are encouraged to bring corroborative information, such as old report cards, previous assessment reports, etc. In the coming years, we expect to Adult ADHD 27 automate this system by making forms available online to be completed and scored electronically.

Review and History of Presenting Problems As with any clinical interview, it is useful to find out how patients have arrived at the decision to seek help. It is important to learn from patients what they view as key problems in their lives, and how their difficulties reflect a change in previous functioning and/or are causing greater functional impairments. We also explore how various circumstantial factors contribute to their troubles, how their problems are affecting their daily lives, what attempts they’ve made to manage these problems, and how their efforts have turned out. It is also useful to ask how the patient first became aware of the diagnosis of ADHD, their knowledge and attitude toward ADHD, and its relevance to their current life circumstances. In many cases, individuals have “self-diagnosed” after reading a popular book on adult ADHD, or hearing from friends that they “seem ADD.” By contrast, some individuals are very skeptical about the diagnosis of ADHD and are pursuing the evaluation solely at the urging of a loved one. Such information is useful for considering whether a particular patient is either over- or underreporting symptoms based on her or his pre- formed view of ADHD. When discussing possible explanations for their presenting difficulties, it is reasonable to ask patients, “If it turns out that there is no evidence of ADHD, how do you think you would make sense of the problems you are experiencing?” It is all too easy for patients and clinicians to become overly focused on the ADHD aspect of an evaluation and to forget to adopt a wider-range view of individuals’ well- being. A simple question along the lines of, “Is there anything else going on in your life other than the possible role of ADHD that you think is significant or that you view as a problem to be addressed?” Finally, as always, it is important to assess patients’ personal strengths and their positive support systems and adaptive resources. As a transition to the rest of the interview, the specific goals for the evaluation are clarified, including what the patient hopes to achieve from the evaluation, to whom the results will be sent, and how they will be used.

Developmental History Although a discussion of past examples of coping difficulties and other historical factors

Downloaded by [New York University] at 12:14 14 August 2016 often arise in the review of presenting problems, it is essential to take a systematic developmental history. The relevant topics to cover include family history, academic history, vocational history, and medical and psychiatric history.

Family History/Preschool Functioning We start our developmental history by constructing a cursory genogram of the current family constellation and family of origin, which often lends itself to discussion of highlights about family functioning and relevant dynamics. We inquire about family medical, psychiatric, and substance use histories as well as about any history of ADHD, learning differences, or other developmental conditions in the family. 28 Adult ADHD After obtaining adequate family information, we review the patient’s developmental history from birth to starting school. This review includes any reported problems during pregnancy, delivery, and early development. We ask about attainment of developmental milestones and the presence of prenatal risk factors (i.e., maternal cigarette smoking) or infant and childhood diseases or injuries that could contribute to ADHD-like symptoms. In such situations, it can be invaluable to get the input of patients’ parents or other individuals who knew them in childhood, in person or by questionnaire, phone call, e-mail, etc., whenever possible. Another useful question to ask is, “Are there any stories of what you were like around the house before you started school?” In some cases, there is useful information, such as the person who was assigned a “sibling shadow” because the patient repeatedly wan- dered away from home looking for trees to climb; another patient reported that the lower cabinets and bookshelves were bare because he “got into everything.” No single example is diagnostic, but these examples may be part of a broader developmental tap- estry of functioning and later coping difficulties that informs the assessment.

Academic History In most standard clinical evaluations for individuals pursuing psychological or psychiatric treatment, ascertaining the number of years of education and any terminal degrees completed by patients constitutes an adequate review of academic history. In the case of an adult ADHD evaluation, however, even if someone has earned an advanced degree, there will be important details about how the patient performed in school that are not always reflected educational attainment or grades. Reviewing academic and behavioral performance at each level of education, including asking about classes failed or left incomplete, grade levels repeated, required summer school, the need for special academic support, and classes dropped in college, provide telling information. It is also helpful to review how the individual handled transitions to successive levels of education, such as moving from grade school to middle school, middle school to high school, etc. Each new level of school presents novel and increased demands for independent functioning and corresponding increases in the amount and difficulty of work. Likewise, asking questions about a patient’s ability to listen and pay attention in lectures, complete reading assignments, organize and complete written assignments, manage time and maintain organization in their studies, take timed, in-class exams, and complete homework and other assignments requiring persistence of

Downloaded by [New York University] at 12:14 14 August 2016 effort across time (i.e., essays) and submit them by a deadline provides vital clinical information about executive functioning. Even in cases in which a student earned high grades, it is useful to inquire about how those grades were achieved. We have heard many stories of patients who “got by” in school without doing any assigned reading or by relying on extra credit assignments, and were able to move on to the next level of education having earned good grades but without necessarily being adequately prepared in terms of having sustainable academic skills. In one case, a college student admitted that he was only able to focus on reading the first several pages of assigned reading. He compensated by dominating the discussion in the next class based on the few pages he had read and understood! While he earned high marks for class participation, he was unprepared for exams. We have heard similar Adult ADHD 29 stories about students getting by in school without doing assigned readings or benefiting from sympathetic teachers or diligent parents who provided structure, supervision, and other “academic scaffolding.” Serious problems arise when the student does not have access to these buffers and supports at subsequent levels of schooling and finds herself or himself unable to implement the necessary coping skills.

Vocational History For adults in the workforce, a similarly detailed review of work history is indicated. Even when an individual has a seemingly stable employment history, it is useful to ask about the presence of work-related difficulties, such as getting projects done on time, arriving at work on time, being disorganized, or having conflicts with coworkers or superiors. Similar to exploring the individual’s “learning and studying processes” when they were in school, reviewing various common tasks encountered in the workplace (e.g., writing reports, organizing projects, etc.) provides important clinical data. It is useful to review reasons for changing jobs in the past, and specific job duties or environments that have proven to be consistently challenging for the individual. Self-employed individuals should be queried regarding managing the unique work demands faced by them (e.g., customer relations, scheduling work, financial accounting) and whether or not their self-employed status was arrived at by choice or by default (e.g., “I couldn’t hold a job anywhere else.”). Finally, stay-at-home parents with ADHD often face many difficulties keeping up with the demands of parenting, managing a household, and other duties that should be explored fully. In reviewing both academic and occupational functioning, it is important to inquire about positive experiences in these settings, too. Patients might remember particularly supportive teachers, accommodating supervisors, or settings that provided a “good fit,” where the individual performed well. For example, some adults with ADHD remember that they kept up with homework better during a sports season when their schedules were more structured and when they had daily vigorous physical activity; workers have reported better performance on projects when there were weekly progress meetings.

Medical and Psychiatric History A review of medical and psychiatric treatment history is useful to rule out the presence of medical disorders or brain injuries that could contribute to complaints of inattention

Downloaded by [New York University] at 12:14 14 August 2016 or impulsivity. If there have been treatments for medical or psychiatric conditions, including ADHD, inquire about past diagnoses and assessments, and response to previous treatments. In some cases, the clinical interview may unearth symptoms of a psychiatric or medical condition that could mimic the symptoms of ADHD. We explicitly ask about history of head and other physical injuries, sleep problems, substance use, and nicotine and caffeine use. We also ask about driving behaviors (including speeding tickets, accidents, or charges of DUI) and about legal difficulties. A medical consultation might be indicated to investigate suspicions of organic causes of symptoms, as in the case of a sleep study to rule out a sleep disorder, blood work to rule out thyroid problems, or an EEG to rule out seizure disorder. Atypical presentation of “attention problems,” such as might be seen in Lyme disease or chronic fatigue syndrome should be 30 Adult ADHD carefully worked up. A thorough diagnostic interview is crucial to assess for psychiatric disorders that may mask, coexist with, or mimic ADHD symptoms.

Structured Diagnostic Interview As described earlier, adults with ADHD will likely present with at least one additional psychiatric diagnosis. Moreover, all requested evaluations for adult ADHD do not necessarily end up revealing sufficient evidence to support a diagnosis of ADHD. Other factors, such as mood, anxiety, substance use, learning disorders, personality characteristics, or some combination of issues might better explain an individual’s problems. Even if it is concluded that the presenting symptoms are not consistent with ADHD, it is important to help patients identify and get help for their difficulties. Thus, a structured diagnostic interview is a vital facet of an adult ADHD evaluation. (As an aside, some of our most satisfying “ADHD” assessments have been cases in which there was not sufficient evidence of ADHD, but we helped these individuals better understand the source of their difficulties and direct them to helpful treatments.) We administer the Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 1997) to each patient. (We anticipate transitioning to a SCID-5 or other relevant structured interview when it becomes available, but we do not anticipate that the different version will change the spirit of the discussion that follows.) The SCID offers modules for assessing for the presence of substance abuse/dependence, mood disorders (including bipolar disorder), anxiety disorders, psychotic disorders, and eating disorders. As we tell patients, our goal is to obtain a comprehensive picture of various factors that might be relevant to the problems they are experiencing. By the time we reach the SCID, we have already gathered a good deal of information relevant to psychiatric status to help streamline this process, but it is useful to go through the modules systematically. During the review of medical and psychiatric history discussed in the previous section, we explicitly inquire about a history of any traumatic events, which is also a focus of the Posttraumatic Stress Disorder (PTSD) module of the SCID. Over the years, we have evaluated several individuals who have disclosed (sometimes for the first time) a history of childhood trauma. The “attention” difficulties they encountered actually represent persistent affective interference, dissociation, and the developmental effects of trauma on cognitive functioning (Ramsay, Rosenfield, & Harris, 2011). We admit that it can be difficult to disentangle PTSD from ADHD—if the person had

Downloaded by [New York University] at 12:14 14 August 2016 not experienced the trauma, would they still have exhibited features of ADHD? The situation in which a trauma leading to PTSD occurred during childhood and corresponds with symptom onset most often lend itself to specialized treatment for PTSD. On the other hand, we have encountered individuals who exhibited a clear developmental profile consistent with ADHD in childhood who (unfortunately) experienced a trauma in late adolescence or adulthood, representing a true coexistence of ADHD magnified by later onset PTSD. There is no module for ADHD in the SCID; therefore we use a combination of clinical interview, symptom checklists, norm-based inventories, and reviewing corroborative information to assess ADHD symptoms as well as information regarding the developmental history. Finally, we administer various mood, anxiety, and personality questionnaires to Adult ADHD 31 gather a wide array of objective data about patients’ symptoms and functioning that are diagnostically helpful, clinically relevant, and informative for patients.

Assessing Symptoms of ADHD and Related Features Of course, the primary reason for conducting such a comprehensive evaluation (and what sets it apart from a standard psychiatric evaluation) is the assessment for symptoms of ADHD. Throughout the aforementioned components of our evaluation, we are listening for and asking about symptoms of ADHD in patients’ lives, always considering possible alternative explanations. A good clinical interview is invaluable in assessing for ADHD symptoms. It is necessary, however, to augment the clinical data collected in the interview with results from checklists and inventories measuring ADHD symptoms, both in childhood and adulthood.

Inquiring About ADHD Symptoms It is helpful to inquire directly about patients’ functioning in a number of life domains often affected by ADHD. Questions focused on how individuals handle work and/or school, including managing time, organizing paperwork and other materials, working independently, and meeting deadlines (including doing so by rushing at the last minute) can be informative, providing examples of executive functioning in everyday life. Similar questions about how individuals’ manage their personal affairs, including paying bills (and incurring late fees), keeping up with household chores, keeping appointments, adhering to a financial budget (including questions about impulsive spending), and maintaining organization (including questions about losing things) can shed light on how they handle the business of adult life. Two domains that are also important to explore are managing one’s physical well- being (i.e., health) and ones’ relationship with technology. Questions about the person’s ability to pursue and maintain hobbies or other personal endeavors as well as personal health maintenance can identify the extent to which the individual carries out self-care behaviors. In some cases, the person may spend too much time on personal interests to the exclusion of other pressing responsibilities. However, we often hear that inefficiencies in other life domains can interfere with self-care (“How can I justify exercising when I am so far behind on other things?”) or recreation (“I cannot sit through a television program.”). In rare cases, there are striking examples of the harmful effects of executive

Downloaded by [New York University] at 12:14 14 August 2016 dysfunction on health, such as an individual not filling or losing prescriptions, or not following through on physician recommendations for an otherwise treatable medical condition. In some ways, features of ADHD, particularly procrastination, can be conceptualized as a quasi-autoimmune disorder in that it attacks the very processes that are designed to benefit our well-being. The interaction with technology is another important area to actively inquire about, particularly within the current cohort of older adolescents and young adults who have grown up as a “wired generation.” In many ways, dealing with problematic use of modern technology is akin to dealing with an eating disorder. One cannot enter a 28-day detox program for food when facing disordered eating behaviors; rather, it is vital to develop a healthy relationship with food. Likewise, although it is possible to survive 32 Adult ADHD without access to current technology, most individuals must learn to develop a healthy relationship with various technological gadgets. From a behavioral standpoint, technology provides a handy way to escape from other higher priority, though less enjoyable tasks that nonetheless are important for the individual to complete. General questions about patients’ assessment of their own abilities to meet day-today responsibilities, fulfill personal obligations, learn from mistakes and change behaviors, and, finally, fulfill their own sense of potential can be revealing. Answers to questions and open-ended narratives recounted by adults with ADHD are often heart wrenching. Most individuals without ADHD recount isolated incidents of limited, circumscribed difficulties. Individuals with ADHD, on the other hand, often report numerous and recurring examples of functional problems that cause them great suffering almost every day.

Standardized ADHD Symptom Checklists We use symptom checklists to help assess the presence of both childhood and current adulthood symptoms of ADHD. The combination of checklists and interview allows clinicians to ask follow-up questions about specific symptoms patients may or may not endorse (particularly when there seems to be discordance between interview and checklist responses or even intra-individual differences in responses). The available evidence suggests that a combination of self- and observer-report of symptoms of ADHD along with associated functional impairments provides reliable diagnostic information (Bark- ley, Knouse, & Murphy, 2011). Observer ratings of symptoms and functioning are highly desirable in the assessment of ADHD. DSM-5 guidelines explicitly emphasize the role of using ancillary information as a standard for the diagnostic process. Of course, clinical review and follow-up are indicated in cases of discrepancies between reporters’ ratings. Overreporting of symptoms (particularly when there is the specter of secondary gain and/or questionable “impairments”), or, more often, underreporting of symptoms in cases in which there are obvious problems demand careful scrutiny. The Barkley Adult ADHD Rating Scales— IV (BAARS-IV; Barkley, 2011a) provides a convenient-to-use, norm-based symptom checklist. The BAARS-IV includes both self- and observer-report forms for both childhood and adult symptoms of ADHD. It has the added benefit of providing a module for rating SCT/CDD symptoms in adulthood, to our knowledge the first norm-based SCT/CDD assessment. Patients complete the self-

Downloaded by [New York University] at 12:14 14 August 2016 report forms for both childhood and adulthood symptoms, and we ask patients to obtain ratings from significant others, such as parents, siblings, spouses, and roommates, whenever possible. The inclusion of collateral data is now considered to be a clinical practice standard. The BAARS-IV items are consistent with DSM-5 diagnostic criteria (which are unchanged from DSM-IV) and provide norms for total ratings as well as symptom counts for each symptom cluster for Inattention, Impulsivity, Hyperactivity, and SCT. A total ADHD score and symptom count also are provided. (For ratings of childhood behavior, a single score for the combination of Hyperactivity-Impulsivity is provided). Symptoms are rated by the respondent on a 4-point scale of severity of symptoms from those that are/were “never or rarely” a problem (“1” or minimal) to those that are/were Adult ADHD 33 “very often” a problem (“4” or severe). According to the scoring instructions, symptoms endorsed as occurring at least “often” (“3” or moderately) are considered diagnostic and are counted for each of the subtypes. Thus, the BAARS-IV is useful because diagnostic questions regarding ADHD can be answered in terms of symptom endorsement as defined by DSM-5 (i.e., at least five of nine symptoms are endorsed as moderate severity in either subtype category) as well as using norm-based ratings of symptom severity. The inclusion of SCT helps provide greater clarity to the functional difficulties of individuals who manifest these symptoms, either distinct from a traditional ADHD presentation or in addition to the characteristic features .

Standardized Adult ADHD Symptom Rating Scales While the classic ADHD symptoms can be assessed in adult patients through a careful clinical interview, the DSM-5 symptoms often do not adequately account for differences in the manifestation of ADHD in adult versus child patients. Relying solely on the presence of DSM symptom criteria is a necessary but insufficient facet of a diagnostic assessment for adult ADHD, particularly considering that the existing criteria were drawn from those developed primarily for children (McGough & Barkley, 2004) and they may not be developmentally appropriate for the assessment of adults (Barkley et al., 2008). Norm-based symptom checklists represents a significant step forward but are still teth- ered to DSM criteria. Standardized objective symptom rating scales such as the Conners’ Adult ADHD Rat- ing Scales (CAARS; Conners, Erhart, & Sparrow, 1999) and the Brown Attention Deficit Disorder Scale for Adults (BADDS; Brown, 1996) help clinicians assess a wide range of adult symptoms of ADHD in adult patients. We have found using both of these scales in our clinic to be beneficial because each provides useful and somewhat nonoverlapping clinical information. The CAARS: Long Version is a 66-item self-report instrument that measures a wide variety of symptoms of ADHD in adult patients. Similar to the BAARS-IV, patients rate each item on a 4-point scale of the occurrence of symptoms ranging from “Not at all, never” to “Very much, very frequently” The CAARS yields a total score and subscale scores (i.e., Inattention/Memory Problems, Hyperactivity/Restlessness, Impulsivity/Emotional Lability, Problems with Self-Concept) measuring a variety of deficits commonly associated with ADHD. Among the subscale scores are three devoted to DSM criteria (DSM-IV Inattentive Symptoms, DSM-IV Hyperactive-Impulsive Symptoms, and DSM-IV ADHD

Downloaded by [New York University] at 12:14 14 August 2016 Symptoms Total) and an additional ADHD Index score that are helpful in corroborating clinical data gathered during interviews. Each respondent’s responses are tabulated and transformed as t-scores (mean = 50; standard deviation = 10) on a profile form that is based on norms compiled specific to both gender and age of the respondent. There also are both brief and screening versions of the CAARS as well as an observer form. The BADDS-Adult Version is a 40-item examiner-administered instrument (though it can be completed as a self-report measure) that measures a wide variety of symptoms of ADHD in adult patients. The BADDS not only examines the ability to sustain attention, but also the ability to get started on work tasks, initiate and sustain attention, maintain effort necessary to complete tasks, regulate moods, and to recall information encountered in daily life. It yields a total score and five subscale scores corresponding to 34 Adult ADHD the previously mentioned components of the executive functions (i.e., Activation, Atten- tion, Effort, Affect, and Memory; Brown, 2013). Each item is rated on a 4-point scale of the occurrence of symptoms ranging from “Never” to “Almost Daily.” Similar to the CAARS, respondents’ responses are tabulated and presented as t-scores on a profile form that is based on adult norms. Despite the usefulness and quality of such objective measures of ADHD symptoms, there is no single test upon which clinicians can rely to accurately diagnose ADHD. Of course, this statement is true for the assessment of most psychiatric disorders, as diagnoses are arrived at only after review of history, clinical interview, and, whenever possible, at least one norm-based measure. However, we do not recommend making a diagnosis of ADHD based on a single score on a single questionnaire. Each inventory and test is part of a broader evaluation designed to gather a wealth of clinical data.

Standardized Ratings of Executive Functioning We have discussed the executive dysfunction model of ADHD in an earlier section. However, the reliable and valid measurement of executive dysfunction as seen in ADHD has been elusive. Several studies have noted the inconsistent findings among tests and measures of executive functioning in samples of adults with ADHD (Biederman et al., 2008; Willcutt, Doyle, Nigg, Faraone, & Pennington, 2005). One source of this conundrum may stem from the emerging realization that a disorder of executive dysfunction cannot be consistently documented by existing office-based cognitive tests (Barkley, 2011b; Brown, 2013). That is, the commonly used executive function tests, in fact, do not actually measure the executive functions, at least using the definition of self-regulation-in-context we reviewed earlier (Barkley, 1997, 2001, 2011b, 2012b). Various tests of cognitive functioning present tasks that are designed to be approximations of the skills utilized in daily life. These tasks are generally relatively brief and administered in one-on-one, distraction-reduced settings. They provide population- based norms that allow an individual’s performance to be understood in reference to what is considered normative. In a situation such as a vision test, this sort of approximation works well—standing 20 feet from an eye chart, how does your accuracy in identifying differently sized letters compare with what others are able to see at the same distance looking at the same eye chart? This measure is a reasonable approximation that translates well to most situations

Downloaded by [New York University] at 12:14 14 August 2016 in the real world requiring corrective lenses, such as reading text or road signs. The executive functions, on the other hand, are difficult to assess out of context. They operate to help organize behavior across time and, particularly for adults, involve persistence of effort at repeated points across time, often without supervision, and without immediate reward. Thus, the traditional neuropsychological testing context involves interactions with an examiner (or at least the knowledge that someone will be checking on performance) and time-limited tasks administered in a sterile, distraction-reduced setting. Using the example of an eye exam, the related executive function test would be consistently wearing the eye glasses, keeping track of and adequately maintaining them, and scheduling and keeping follow-up appointments with the optometrist. That being said, there may be some easy-to-administer tests that provide useful clinical and diagnostic Adult ADHD 35 information within the context of a comprehensive evaluation, such as brief tests of auditory working memory (Brown, 2013). Based on the definition of the executive functions that emphasizes self-directed behavior in context, assessment involves measuring behavior and functioning in various life settings. As cited earlier, Kessler et al. (2010) and Barkley (Barkley et al., 2008; Bark- ley, 2011b) reported that symptoms of executive dysfunction were strongly associated with the diagnosis of ADHD and with life impairments, thus making it a more accurate measure of impairment than testing. Consequently, a norm-based inventory of the executive functions in everyday life is a helpful component of an ADHD evaluation. The BADDS (Brown, 1996) was an early attempt to identify examples of executive dysfunction in daily life, although there are more recent scales that specifically target executive functions and have a stronger norm-base. The Behavior Rating Inventory of Executive Function (BRIEF® ; Roth, Isquith, & Gioia, 2005) is a relatively widely used self- report (and observer-report) measure of the executive functions, but it does not specifically target ADHD. More recently, we have included the Barkley Deficits in Executive Functioning Scale (BDEFS; Barkley, 2011b) in our assessment protocol. The BDEFS provides a norm-based measure of executive dysfunction and includes both self- and observer-report forms. There are five subscales of the BDEFs: Self-Regulation to Time, Self-Organization/ Problem Solving, Self-Motivation, Self-Restraint, and Self-Regulation of Emotions. Items are rated by the respondent on a 4-point scale of severity of symptoms from those that are/were “never or rarely” a problem (“1” or minimal) to those that are/were “very often” a problem (“4” or severe). Total scores are calculated for each domain and compared with age- and gender-based norms. A Total EF score is calculated as well as an ADHD-EF Index score that provides in indication of risk for ADHD.

Ratings of Functional Impairments It is usually the struggles or impairments in daily life that lead individuals with ADHD to seek assessment and treatment rather than mere symptom complaints. It is rare that people contact our program for specific help with inattention or impulsivity. Rather, real-world impairments stemming from ADHD symptoms, such as academic, workplace, or relationship issues prompt their requests for assistance. The combination of clinical and diagnostic interview, history taking, and review of various measures of ADHD and executive functioning often reveals ample evidence of

Downloaded by [New York University] at 12:14 14 August 2016 impairments in an individual’s life that warrant intervention. It is also useful to obtain a systematic measure of functional impairments or quality of life when further documentation is needed. We obtain a measure of quality of life from the Adult ADHD Quality of Life (AAQoL; Brod, Johnston, Able, & Swindle, 2006) questionnaire. This inventory is a brief, self- report measure of satisfaction with different domains of life and adult role functioning. The Weiss Functional Impairment Rating Scale (WFIRS; Weiss, 2010) is another viable option in which different domains of life and items within each domain are rated by the individual with ADHD and for which there is an observer form, too. The Barkley Func- tional Impairment Scale (BFIS; Barkley, 2011c) provides a norm-based measure of functioning that is not limited to ADHD. 36 Adult ADHD Mood and Anxiety Ratings We obtain self-report ratings of depression, anxiety, and hopelessness symptoms as part of the initial evaluation. In particular, we use the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996), Beck Hopelessness Scale (BHS; Beck & Steer, 1989) and the Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990) in the home packet. Up until recently, we have used the Beck Anxiety Inventory (BAI; Beck & Steer, 1990); however, we observed that the BAI total score underestimates the level of anxiety experienced by many of our ADHD patients. This may be related to the fact it is commonly used to identify many somatic symptoms of anxiety, such as those also seen in panic attacks. Patients with ADHD most often experience nonsomatic anxiety symptoms. The BDI-II is a 21-item self-report scale that monitors current mood symptoms. Patients rate their current level of distress on various symptoms of depression, such as self-criticism, energy level, and suicidal ideation. Each item is rated from “0” (indicating that it is not a problem) to “3” (indicating a severe problem). The total score can range from 0 to 63. The total scores can be used to identify minimal (0–13), mild (14–19), moderate (20–28), or severe levels of depressed mood (29+). The BHS is a 20-item self-report instrument that monitors pessimism and demoralization. Patients rate each item as either true or false as it pertains to their current attitude about the future. Items are counted when endorsed in the hopeless direction, resulting in a range of scores from 0 to 20. The total scores can be used to identify minimal (0–3), mild (4–8), moderate (9–14), or severe levels of hopelessness (15+). The PSWQ is a 16-item, self-report inventory that is designed to capture the exces- siveness, pervasiveness, and uncontrollability of pathological worry. Items are scored on a 5-point scale (with some items reverse scored) the sum of these scores is the total score that ranges from 16 to 80. The total score can be used to identify low (16–39), moderate (40–59), and high (60–80) levels of worry. As an aside, when inquiring about anxiety with some patients with ADHD, rather than describing feeling “overwhelmed” by stressors, they report problems of being “underwhelmed.” That is, these individuals report that, based on their circumstances, such as being significantly behind in their schoolwork, facing the financial effects of impulsive spending, etc., they experience dangerously low levels of anxiety or concern. As one patient stated, “I just want to reach the point at which I can feel ‘whelmed.’”

Neuropsychological Screening Downloaded by [New York University] at 12:14 14 August 2016 As part of our comprehensive assessment, we use a brief collection of neuropsychological screening tests. We do not use them to establish impairments associated with ADHD or executive functioning, but rather to measure overall cognitive functioning and to learn how patients handle tasks that require sustained attention, impulse control, and working memory. We also use these tests to screen for learning differences that can be incorporated into the diagnostic and treatment plan. For example, there may be evidence that indicates the need for further psycho-educational assessment of learning impairments, or neuropsychological assessment of more pronounced cognitive impairments that are not accounted for by ADHD. There are many occasions in which testing results confirm reports of real world difficulties and provide a measure of these Adult ADHD 37 problems. In some cases, we use them to measure medication treatment effects. Finally, patients are often surprised when findings indicate areas of relative strength, particularly when their assumption was “I thought I did horribly on that.” This incongruence may reflect an overgeneralized negative self-expectation held by the individual or can be used to illustrate the impact of executive dysfunction (i.e., ADHD is not the absence of the “capacity” for a skill, but the inconsistent “implementation” of the skill). An enduring component of our neuropsychological screening battery is the Selective Reminding Test (SRT; Buschke, 1973; Spreen & Strauss, 1991). The SRT is a list of 12 words that is aurally presented to a patient across multiple learning trials. The respondent is instructed that he or she, after hearing the entire list, is to repeat back all the words in any order. After the respondent recalls as many words as possible, the examiner identifies the omitted words, and the respondent is instructed to recite the entire list of 12 words again. The test goes on for 12 trials or until the respondent accurately recites the entire word list for three consecutive times, whichever occurs first. The SRT provides a measure of auditory working memory encoding, retrieval, and consolidation. The measure is standardized by age and by gender, and includes alternate forms for retesting. To obtain a measure of delayed recall, the patient can be asked to repeat the list again after 5 minutes of other activities or at greater time increments. We also use four specific subscales of the Wechsler Adult Intelligence Scale—Fourth Edi- tion (WAIS-IV; Wechsler, 2008) to provide a brief summary of intellectual functioning, performance on specific cognitive skills, and to detect the presence of a learning disorder. We administer the Vocabulary, Block Design, Digit Span, and Digit Symbol Coding subscales to assess verbal skills, nonverbal problem solving, auditory working memory for numbers, and cognitive processing speed, respectively. Although specific patterns of sub- test scores and splits between verbal and performance measures have not been proven to be reliably associated with a diagnosis of ADHD (Mapou, 2009; Murphy & Gordon, 2006), these subscales provide an overview of strengths and weaknesses patients often find informative. A computerized continuous performance task is commonly used in evaluations for ADHD. Although we emphasize real-world executive functioning, the ability to attend to a task and to execute the rule for that task is a useful foundational skill to assess. We use the Quotient ™ ADHD System, which is a computerized continuous performance task that also provides measures of head and leg movements during the task that was originally used as a research task and continues to be used in studies (Sumner, 2010; Teicher, Polcari, Fourligas, Vitaliano, & Navalta, 2012). In addition to providing data on sus-

Downloaded by [New York University] at 12:14 14 August 2016 tained attention, the movement data provide a correlate of the symptoms of ADHD. The combination of data on performance during the task, including measures of attention shifts; percentage of time attentive, inattentive, impulsive, or disengaged; and motor movements during the test all provide useful information. We have recently added the F-A-S Task test (FAS; Mitrushina, Boone, Razani, & D’Elia, 2005) to our neuropsychological screening because verbal fluency often correlates with general problem-solving ability. The FAS represents a test of verbal fluency that involves the administration of three, 1-minute trials. The respondent is asked to list as many words as he or she can that start with the target letter in 1 minute, with each trial having a different letter (i.e., F, A, or S). The respondent is instructed that proper names and plurals of previously cited words will not be counted. The examiner keeps track of 38 Adult ADHD the responses and tabulates the total score that is corrected for education level. The final score is presented as a z score (mean = 0; standard deviation = 1). The assessment of these cognitive skills helps provide a wider, clinically useful formulation of ADHD and it associated impairments. Likewise, assessment of comorbidities is an important facet of a comprehensive assessment. In the next section, we discuss some of the common comorbity patterns seen in adult ADHD and their clinical relevance for the overall conceptualization.

Adult ADHD and Comorbidity As was mentioned earlier, comorbidity is the rule rather than the exception in adult ADHD. In a majority of cases, long-standing difficulties experienced by individuals become intertwined with various other developmental frustrations, emotional symptoms, and life problems. Many individuals initially enter mental health treatment for depression or anxiety only to obtain partially successful results due to unrecognized, more predominant ADHD; in some cases, such as seen in reverse comorbidity studies, ADHD complicates the course of other conditions, such as bipolar disorder or substance use. Most of the symptoms characteristic of ADHD and, by extension, executive dysfunction, are manifestations of poor self-regulation. In the previous edition of this book, we noted the interaction of the executive functions with emotional self-management. Since then, there has been increased appreciation that emotional regulation is itself an executive function (Kessler et al., 2010) and that deficient emotional self-regulation (DESR) is one of the defining characteristics of ADHD (Barkley, 2010; Surman et al., 2011). It should be noted that the role of emotions in ADHD had previously been identified by Wender (Wender, 1995) and others, although this was not fully conceptualized until recent years. DESR (Barkley, 2010) is not the same as the truly comorbid features of a mood or anxiety disorder, which represent discrete disorders marked by symptom cluster, severity, and course. Rather, DESR represents difficulties effectively managing emotional responses to environmental triggers to which anyone—ADHD or not—will have an emotional response. Individuals with ADHD are more likely than non-ADHD peers to have more difficulties managing these typical emotional reactions, either positive or negative, thereby creating another source of distraction and disruption to executive functioning. Moreover, DESR may help explain the frequency with which we see patients with subthreshold manifestations of mood, anxiety, and other emotional distress. In fact, we previously wondered whether one of the benefits of CBT for adult ADHD

Downloaded by [New York University] at 12:14 14 August 2016 might be its effectiveness in managing coexisting emotional distress, thereby enabling individuals to focus their energies on managing ADHD (Ramsay & Rostain, 2003). In light of the recognition of the role of DESR in ADHD, however, it is probably the case that CBT effectively treats this domain of executive dysfunction by helping individuals with ADHD overcome the negative anticipations and emotional discomfort they associate with getting engaged in a task. Research examining the distinct association of distorted thoughts, mood, and anxiety in samples of adults with ADHD (Knouse, Zvorsky, & Safren, 2013; Mitchell, Benson, Knouse, Kimbrel, & Anastopoulos, 2013; Strohmeier, Rosenfield, DiTomasso, & Ramsay, 2013) and outcomes from a course of CBT for adults with ADHD who declined concurrent medication treatment (Ramsay & Rostain, 2011) further support this conjecture. Adult ADHD 39 Regardless of how these difficulties align, the fact that they co-occur for many adults with ADHD is an important part of the diagnostic picture and deserves special attention. Our discussion regarding comorbidity is meant to be applicable for individuals with ADHD experiencing coexisting disorders as well as those who struggle with briefer episodes (e.g., “shadow syndromes,” Ratey & Johnson, 1997) during which they feel derailed by their emotional reactions to life’s daily demands.

Depression Excessive feelings of sadness, physical feelings of fatigue or tearfulness, lack of enjoyment or pleasure (e.g., anhedonia), and increased negative evaluations of oneself, the world, and the future experienced more often than not over at least a few weeks are some of the hallmarks of major depression. For adults with ADHD who already struggle with procrastination and difficulty concentrating, symptoms of depression will magnify problems with attempts to initiate behavior or sustain attention. Some individuals who are depressed may mistakenly think they have ADHD because of their distractibility and poor follow-through. One key difference between depression and ADHD is that individuals who have experienced depression usually report that their symptoms (including concentration and restlessness) improve as their mood improves, even in cases of chronic depression. For individuals with ADHD, these functional problems persist regardless of their moods. There might be relative improvements with improved mood, although this might be the result of being less reactive to typical concentration difficulties. By contrast, non-ADHD individuals with depression do not display a developmental trajectory characterized by persistent executive dysfunction in the absence of depression. Of course, depression and ADHD often coexist, whether the depressed mood develops as a result of repeated life frustrations and demoralization, or whether both disorders develop in a true case of co-occurrence. In our clinical experience, the combination of depression and ADHD leads individuals to be extremely sensitive to frustration and failure, and to give up on tasks easily at the very first sign of difficulty (or perceived difficulty). Thus, patients with comorbid ADHD and depression may be significantly underfunctioning or may have adopted a stoic attitude of “settling” for their circumstances, even if they express dissatisfaction with these circumstances.

Anxiety Downloaded by [New York University] at 12:14 14 August 2016 Anxiety is the most common comoribidity seen in adults with ADHD (Barkley et al., 2008; Kessler et al., 2006; Safren, Lanka, Otto, & Pollack, 2001; Schatz & Rostain, 2006). Most forms of anxiety are associated with feeling “on edge” or “keyed up,” difficulty concentrating (e.g., mind going blank), worry, and irritability. These feelings are associated with an overriding perception of a threat. Such feelings can be very adaptive when individuals face situations involving a degree of risk, such as the approach of a strange dog or preparing to cross a busy city street. Most people describe situations in daily life that activate worry, such as dealing with social interactions, with challenging tasks, or with uncertainty (e.g., “what-if” reactions). Individuals with chronic anxiety experience levels of arousal that are either out of proportion with the situation or that result from a 40 Adult ADHD magnification of the appraisal of threat, leading them to avoid various situations. ADHD adults often describe similar patterns of avoidance regarding tasks they have found difficult or frustrating in the past, a learned habit that leads to procrastination. Not surprisingly, many individuals who are anxious may assume they have ADHD because their performance and follow-through on tasks are inconsistent, and their worries may interfere with their concentration. Anxious individuals can also engage in “impulsive” behaviors to avoid facing anxiety-producing tasks. However, anxiety is most often linked to specific contexts and tasks associated with perceived threat or anticipatory discomfort and is not apparent in most activities of daily living (e.g., paying bills, or tasks requiring persistence, such as maintaining an exercise regimen). Individuals with ADHD often report that their pervasive and enduring difficulties related to anxiety emerged as a consequence of ADHD interfering with daily life. This finding may be the result of a true coincidence—the fact that some individuals develop symptoms of both disorders. In other cases, however, anxiety develops secondary to the symptoms of ADHD. We have hypothesized that the ADHD-anxiety connection reflects difficulties associated with compensatory self-regulation efforts. That is, anxiety is a great motivator. There is adaptive anxiety and it has been found to be associated with optimal performance, with too little anxiety being associated with poor preparation and too much anxiety with underperformance. Many adults with ADHD engage in “brinksmanship,” or waiting until the proverbial “last minute” before something is due to start working on it or at least to complete the bulk of the work. For many adults with ADHD who rely upon “brinksmanship,” we often hear accounts of a progressive escalation of the level of “threat” and corresponding anxiety required for task engagement. For example, as tasks increase in their difficulty, such as moving from high school to college-level assignments and tests, or being given greater workplace responsibilities, tasks become more threatening. Hence, there is greater temptation to procrastinate and avoid them (i.e., the strength of negative anticipations and the emotional aversion is greater), requiring greater levels of anxiety (i.e., motivation) to trigger behavioral activation and task engagement. Clinic-referred adults with ADHD often encounter problems with poor follow-through, running out of time, not anticipating difficulties or allowing enough time for unexpected difficulties, and/or producing substandard work based on this avoidance pattern.

Bipolar Disorder

Downloaded by [New York University] at 12:14 14 August 2016 The quintessential feature of the bipolar spectrum disorders is significant fluctuation in mood states, most often swinging between an “up” mood (mania, hypomania) and a “down” mood (depression). Although full-blown manic symptoms include psychotic symptoms or dangerous behaviors requiring hospitalization to stabilize, at lower points on the continuum, mania and hypomania are associated with varying degrees of decreased need for sleep, racing thoughts, impulsivity, increased activity level, risky behaviors, and heightened confidence. Many of these lower-level bipolar complaints are similar to those reported by some adults with ADHD who often describe a tendency to hyperfocus for longer-than-average times (which is more accurately described as perseveration), or to be particularly productive and energetic in circumscribed, unplanned bursts. However, these periods tend to be brief compared with episodes of mania or hypomania. Adult ADHD 41 Although many adults with ADHD describe problems falling asleep because they “cannot turn off (their) thoughts,” these sleep difficulties are qualitatively different than those described by individuals with bipolar spectrum disorders. In the case of adults with ADHD, our experience has been that they describe feeling tired but unable to fall asleep. This could be secondary to procrastination, perseveration (e.g., nondirected Internet search, computer games), lack of awareness of time, poor judgment about need for sleep, or sleep onset difficulties (e.g., melatonin deficiency). Thus, rather than having decreased need for sleep, individuals with ADHD who do not sleep enough usually end up feeling tired the next day or oversleep to compensate for their sleep debt. By contrast, individuals experiencing symptoms of hypomania or mania, conversely, often describe not feeling tired and seemingly being able to function well with decreased sleep. Their activities during these mood periods seem to be more goal directed and fall outside their typical behavioral pursuits, such as rearranging the furniture in a room late at night or engaging in excessive spending or uncharacteristically risky behaviors. Bipolar spectrum disorders can also be manifested as ongoing agitation or anger. Adults with ADHD often describe brief outbursts of anger or other emotions when upset (i.e., DESR), but then “cool off” afterwards and often recognize that they overre- acted. Whereas individuals with bipolar disorder often describe a return to a semblance of normalcy between mood swings, individuals with ADHD struggle with their symptoms almost daily. Of course, individuals can manifest symptoms of both disorders, which creates a tricky combination for both diagnosis and treatment planning (Karaahmet et al., 2013; Klassen et al., 2010; Nierenberg et al., 2005). Individuals with the comorbidity of ADHD and a bipolar spectrum disorder often experience extreme instability in functioning and, in turn, with their sense of self. Even if they have managed to avoid major disruptions in their lives, such as divorce or unanticipated job changes, they may be prone to reacting strongly to the stress associated with the demands and hassles of daily life.

Substance Abuse Untreated ADHD is a risk factor for lifetime history of substance abuse (Charach, Yeung, Climans, & Lillie, 2011; Upadhyaya & Carpenter, 2008; Wilens, 2011; Wilson, 2007). On the other hand, substance abuse is known to impair various cognitive functions and to create severe functional problems that may appear similar to the symptoms of ADHD. A good historical interview is usually sufficient for determining if there were emerging

Downloaded by [New York University] at 12:14 14 August 2016 symptoms of ADHD in childhood that predated the onset of substance use and/or even- tual abuse. In fact, many “addiction medicine” clinicians subscribe to the “self-medication” hypothesis (Khantzian, 1985; Wilens, 2011) in which it is posited that individuals use substances in an attempt to manage uncomfortable symptoms. Nicotine, alcohol, and marijuana are the most commonly reported substances of abuse among individuals with ADHD (e.g., Upadhyaya & Carpenter, 2008; Wilens, 2011). Patients often describe the effects of their substance use as “quieting down” their brains, “blurring the edges” to allow them to focus, relieving associated stress and anxiety, and sometimes being used to aid in sleep. However, it may also be true that individuals who experience difficulties related to impulsivity and poor self-control are both at higher risk for engaging in risky 42 Adult ADHD behaviors (such as substance abuse) without considering the negative consequences and have a harder time reducing their addictive behaviors. In addition to the physiological cravings that contribute to the maintenance of ongoing substance abuse, there are many associated emotional, cognitive, and behavioral patterns that further maintain substance use. Emotional distress or physical discomfort may lead a person to use in order to gain relief (e.g., drinking alcohol to reduce anxiety related to falling behind at work); beliefs about oneself and substance use may underlie rationalizations for ongoing abuse (e.g., “Smoking pot opens up my creativity”); and behavioral habits may create automated patterns of substance use (e.g., smoke pot after classes are done for the day). Whether substance use develops as a form of self-medication for ADHD, because of poor self-regulation, through of combination of these two factors, or for some other reason, it becomes a key part of the diagnostic picture and treatment plan. It is important to assess for substance use histories and current drug use during the initial evaluation. Although a less common substance of abuse among adults with ADHD (van Emmerik-van Oortmerssen et al., 2012), if an individual has tried cocaine, it is interesting to ask about her or his experience with the drug. Very often we hear individuals say that they recalled not euphoria or a “high,” but rather an improved ability to focus, though such evidence is not sufficient to confirm an ADHD diagnosis. Some individuals are at risk to develop more extensive substance abuse profiles and histories. The concern about ongoing substance use/abuse is twofold: (1) the substance of abuse will interfere with the therapeutic effects of pharmacotherapy; and (2) the effects of substances will interfere with and undermine the development and use of adaptive coping skills that are central to CBT. Current and severe substance dependence requires treatment and stabilization (i.e., inpatient detoxification and rehabilitation programs) before adequate outpatient treatment for ADHD may begin. However, when patients are able to function relatively adequately despite substance use or abuse, addressing the issue is considered an important focus of the outpatient treatment plan. Substance use behaviors are conceptualized as ADHD-related issues and targeted in the therapeutic agenda. In cases in which there is evidence of substance use patterns that interfere with functioning but that do not reach the level of abuse or dependence, some patients say that they do not wish to change their use. We ask that they be willing to discuss their substance use openly in therapeutic and medication management meetings in order to keep open to possibility of change or, at least, to make informed decisions about the effects on their well-being. Most patients find such

Downloaded by [New York University] at 12:14 14 August 2016 agreements acceptable.

Oppositional Defiant Presentations in Adults With ADHD The formulation of DESR as a central component of ADHD helps to explain the high comoribidity with Oppositional Defiant Disorder (ODD) in children (Barkley, 2010). The combination of a behaviorally disinhibited, emotionally excitable child and an environment with insufficient limits that ends up reinforcing oppositional behaviors provides a model for the development of ODD. In severe and unchecked cases, ODD runs the risk of evolving into Conduct Disorder and then Antisocial Personality Disorder, reflecting disregard for societal rules and for Adult ADHD 43 the rights of others. It is likely that these individuals will have legal records and other significant interpersonal problems. On the other hand, there are many adults presenting for outpatient treatment of ADHD who exhibit milder oppositional patterns characterized by excessive stubborn- ness, inflexibility, contrariness, or flaunting rules that do not result in legal problems but that are impairing, nonetheless. There may be other manifestations of emotional dysregulation, such as argumentativeness or “road rage” that contribute to presenting problems. Research on personality styles among adults with ADHD have reported low scores on agreeableness, or a dim view of relationships and other people in several studies (see Ramsay et al., 2011). Robin, Tzelepis, and Bedway (2008) found that adults with ADHD clustered into two personality styles based on their responses to a personality inventory. One group was characterized as adaptable and optimistic; the second group was characterized as more negativistic. Oppositional behaviors in adult patients with ADHD add a degree of complexity to treatment. These individuals are more likely to externalize responsibility and blame others for their difficulties and, correspondingly, minimize their personal influence on situations and their responsibility for making changes. The therapeutic agenda will likely include issues related to anger/frustration management, dealing with interpersonal conflict, or simply facing and accepting the realities of day-to-day life in terms of pursuing one’s goals in the face of various hassles.

Developmental-Social Learning Disorders An increasingly encountered differential diagnosis involves the overlap of ADHD with developmental-social learning disorders, including Pervasive Developmental Disorder (PDD), Asperger’s Disorder, and other autistic spectrum disorders in adults. They may also exhibit symptoms of Social (pragmatic) Communication Disorder, a new diagnostic classification in DSM-5. In fact, DSM-5 acknowledges that PDD and ADHD can coexist, which was not the case in DSM-IV. We will use the term Social Learning Disorders (SLD) to reflect the central impact of these developmental disorders on social functioning and peer relationships, although impairments may extend to other functional domains. Individuals who present for an evaluation for adult ADHD but for whom there are questions about the presence of a SLD are likely to be relatively high functioning and have not exhibited prominent symptoms of social learning problems that would have

Downloaded by [New York University] at 12:14 14 August 2016 led to previous identification. On the other hand, individuals with ADHD often experience difficulties in social functioning as a result of poor emotional regulation, impulsiveness, lack of follow-through on promises to others due to disorganization, and failure to attend to important social cues and nonverbal information. Initial cues about the possibility of SLD may come from the clinician’s interactions with the patient (or the patient’s interactions with other office staff, colleagues, etc.). Observing interpersonal behaviors, including eye contact, appropriateness in responding to the clinician (e.g., judiciousness in humor, questions, other comments, etc.), voice modulation, and conformity to social cues and relevant social norms might suggest the possibility of a SLD. If a significant other is present during the evaluation, it is helpful to learn whether this person operates as a “social coach,” providing guidance to the individual (e.g., clarifying 44 Adult ADHD questions, curtailing rambling responses, helping the individual determine whether an example is appropriate for the evaluation). In addition to interpersonal behavior during the interview, the developmental history of social behaviors is absolutely essential in assessing potential social learning disorders. In the course of gathering the educational history, inquiring about peer and teacher relationships at each level of education, extracurricular activities or hobbies, and subsequent friendships and dating relationships helps form a developmental picture of social functioning. Social experiences in young adulthood at college and/or in the workplace also help form this social developmental profile. Generally, individuals with ADHD know the social rules but have a hard time implementing them (whether from impulsivity or from not paying attention, or both); they make social errors of commission. On the other hand, individuals with SLDs often have difficulties “reading” or understanding the social rules, thereby avoiding or being on the periphery of social situations; they make errors of omission; extant errors of commission are in turn made unwittingly as a consequence of this lack of ability to “read” people and social situations. In the case of individuals for whom the social learning disorder is primary, social functioning problems are usually central to their seeking an assessment. A common presentation is a young adult who is living at home, is un- or underemployed, and about whom the family is concerned due to lack of direction and initiative as well as lack of social connections. Young adults with ADHD, on the other hand, may have similar presentations in terms of “failure to thrive” in adulthood, but their difficulties in academic or occupational functioning are performance related, such as procrastinating on a job search or having a checkered academic or employment history due to poor time management and poor follow-through. Existing social functioning problems may be the result of impulsivity or poor anger management in interpersonal situations. Regardless of how any of these aforementioned comorbidity patterns develop, the various features interweave with ADHD and life experience to form a braided cord from which patients gain a sense of themselves, the world, and their possible futures. Identify- ing and understanding these connections through a comprehensive assessment is an essential first step in gaining control over and starting to change what had previously been thought to be uncontrollable impulses.

Chapter Summary ADHD is a valid and significantly impairing neurodevelopmental syndrome character-

Downloaded by [New York University] at 12:14 14 August 2016 ized by executive dysfunction that has the potential to negatively impact most domains of adaptive functioning. It is apparent that symptoms persist into adulthood for well over half of children diagnosed with ADHD, but this may very well be an underestimation because there continue to be no empirically based, consensually agreed upon diagnostic criteria designed specifically for ADHD in adult patients. Recent modifications to the official diagnostic criteria in DSM-5 reflect increasing recognition of the unique presentation of ADHD in adult patients. In addition to the persistence of ADHD symptoms, there is virtually no area of adult life that is unaffected by ADHD. Although there is a wide range of severity and number of problems, a lifetime history of ADHD is associated with fewer years of education, Adult ADHD 45 underemployment, more frequent job changes, interpersonal and marital discord, and higher-than-average risk for psychiatric and substance use problems. ADHD appears to be the result of genetic predispositions interacting with environmental factors over time. Its symptoms are associated with altered structure and functioning of particular circuits of the brain, likely the result of multiple factors and potential trajectories. There is great complexity and overlap among the various neural systems and developmental pathways involved in understanding the ADHD brain. The first step in providing help for an adult patient with ADHD is to conduct a comprehensive diagnostic assessment. The core components of such an evaluation are a review of presenting problems and current functioning; comprehensive history; structured diagnostic interview, to assess the presence of comorbid conditions or other conditions that could better explain the presenting problems; and use of objective, and norm-based inventories that measure of childhood and adult symptoms of ADHD as well as executive functioning. Neuropsychological screening or other cognitive testing may be helpful to gather clinical evidence about how patients handle different cognitive demands as well as to screen for potential learning differences and other factors that might affect presenting problems (although most tests do not adequately measure executive functions). Once the diagnosis of adult ADHD has been confirmed and other relevant factors and diagnoses accounted for, attention can turn to developing a treatment plan for addressing the issues and symptoms associated with adult ADHD. The next chapter will describe a treatment model for adult ADHD, with an emphasis on the combination of CBT and pharmacotherapy.

Downloaded by [New York University] at 12:14 14 August 2016 2 Models of Treatment Cognitive Behavioral Therapy and Pharmacotherapy for Adult ADHD

We hope it is clear from the information presented in Chapter 1 that Attention-Deficit/ Hyperactivity Disorder (ADHD) is a lifespan neurodevelopmental disorder. The emerging evidence from longitudinal research of individuals with ADHD indicates that the diagnosis is associated with many negative life outcomes for those affected, including problems in work, school, and relationships, along with increased risk for coexisting psychiatric problems. What is more, adults with ADHD experience psychological effects of living with this developmental syndrome inasmuch as they have been found to have significantly more negative thoughts, are less hopeful about the future, and are less accepting of themselves than are those not affected. Said simply, there is virtually no domain of adult life that is unaffected by ADHD. We also hope that it is clear from Chapter 1 that cognitive behavioral therapy (CBT) and medication treatment offer an effective combination with which to treat the symptoms and impairments associated with ADHD. Each treatment approach makes a distinct contribution to a treatment plan. The specific treatment plan is personalized to the needs of each individual. Many individuals achieve their desired outcomes with a single treatment, such as medication management. Other individuals might need medications to provide foundational symptom relief but then require adjunctive treatments to address specific functional difficulties, such as academic support for college students with ADHD. In cases of severe and/or sweeping difficulties, a well-crafted set of treatment approaches will be necessary, including ancillary services to address impairments that fall outside the clinical realm (e.g., legal counsel or financial advising to deal with potential bankruptcy). The purpose of this chapter is to describe our combined treatment approach “in action.” That is, we will start with a review of the CBT model for adult ADHD and how

Downloaded by [New York University] at 12:14 14 August 2016 it informs treatment with special attention paid to specific interventions used with patients to address a variety of functional issues. We have expanded this section from the first edition to provide more specific “how-to-do-it” tips for clinicians, with even more explicit detail about their implementation provided in the companion workbook. After reviewing CBT, we will consider pharmacotherapy for managing adult ADHD.

Cognitive Behavioral Therapy for Adult ADHD Said all too simply, CBT is a form of psychotherapy that focuses on the interplay of cognitions, behaviors, and emotions in understanding psychiatric disorders, with an emphasis placed on cognitions (thoughts, images, beliefs) in the change process (Beck, 1976). Models of Treatment 47 More specifically, CBT involves helping individuals to recognize their existing maladaptive cognitive and behavioral patterns in order to enable them to modify them with alternative thoughts and beliefs as well as new habits. CBT as a distinct form of psychotherapy was originally designed as a treatment for depression (Beck, Rush, Shaw, & Emery, 1979) and since then has been applied successfully to a number of different disorders, including anxiety and panic disorder, substance abuse, bipolar spectrum disorders, and, more recently, schizophrenia (see Butler, Chap- man, Forman, & Beck, 2006; Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012 for reviews). Even within the CBT family of treatments, there is a range of therapeutic emphasis from clinicians who have a strict behavioral orientation to those who emphasize the role of cognitions. It should be noted that CBT is not an “emotion-free zone”; rather, emotions, emotional management, and related issues are identified as essential components in personal experience and are addressed through behavioral and cognitive methods, including how attitudes about emotions affect one’s experiences of them. Turning our attention to the adaptation of CBT for adults with ADHD, let us be crystal clear that ADHD is not caused by negative thinking. As we described in Chapter 1 , ADHD is the result of a complex interaction of genetic, neurobiological, developmental, and environmental factors. However, in terms of the functional issues described by patients, the experience of going through life with ADHD, particularly when it has gone undiagnosed until adulthood, has potentially important consequences for the belief systems that develop about the self, the world, and the future—known as the cognitive triad (Beck, 1976). Thoughts and beliefs then interact with behaviors and emotions in an intricate web of experience. Nowhere is this more apparent than in adult ADHD where executive function and motivational deficits arguably play a role in all personal endeavors, actions, and interactions. The contemporary CBT model does not maintain that thoughts and beliefs necessarily cause all emotions and behaviors. In fact, emotional processing may precede cognitions, not to mention that one of the hallmark features of ADHD—impulsivity—is characterized as acting without thinking. According to the executive function model, there are the “cool” executive functions (e.g., planning) and the “hot” executive functions (e.g., emotions, motivation) (Cubillo, Halari, Smith, Taylor, & Rubia, 2012). An important focus of treatment is modifying cognitive processes in order to help patients understand their behavioral and executive functioning patterns, automatic reactions to environmental demands, and attempts to use new coping skills and self-view (i.e., self-esteem). Although we emphasize behavioral “follow-through” of coping strategies to manage

Downloaded by [New York University] at 12:14 14 August 2016 the effects of executive dysfunction, the cognitive elements are vital for managing adult ADHD. The cognitive component of CBT is essential to understanding the maintenance and sometimes magnification of many impairments and coping difficulties experienced by individuals with ADHD. Cognitions also play an important role in motivational deficits associated with ADHD and, therefore, represent an important domain for intervention, one that also impacts behavioral (and emotional) management. Recent research has identified that dysfunctional thoughts play a significant and distinct role in the functional difficulties faced by adults with ADHD, often associated with escape-avoidance behaviors, and that is only partially explained by coexisting emotional difficulties (Knouse, Zvorsky, & Safren, 2013; Mitchell, Benson, Knouse, Kimbrel, & Anastopoulous, 2013; Strohmeier, Rosenfield, DiTomasso, & Ramsay, 2013; Torrente et al., 2012). 48 Models of Treatment While the traditional CBT interventions of identifying and changing maladaptive thought patterns and outlooks that are triggered in various situations are paramount in CBT for adult ADHD, it is important for clinicians to appreciate that these in-the- moment reactive, automatic thoughts may only be the tip of the iceberg for some patients. These reflexive cognitions often stem from attitudes, outlooks, and beliefs that represent the culmination of a history of developmental experiences associated with growing up with ADHD, including those associated with strong emotions. These patterns are difficult for most people to change, even more so for adults with ADHD whose executive dysfunction and motivation problems add another degree of difficulty. The CBT case conceptualization offers a framework for understanding how living with ADHD has a unique effect on each patient and, consequently, provides a personalized blueprint for how treatment should proceed. Additionally, the conceptualization helps the clinician come closer to being able to “see the world through ADHD eyes” in order to help the patient make changes in his or her life. At the same time, there are many similarities that emerge across different adults with ADHD with regard to managing the effects of executive dysfunction that provide some general coping principles. Thus, we will start our discussion of CBT for adult ADHD by introducing the case conceptualization that helps guide our psychosocial treatment approach.

Case Conceptualization The CBT case conceptualization is the integrated understanding of the patient’s presenting problems, the relevant developmental history explaining the etiology of the clinical issues, and reasonable indications of future functioning (J. S. Beck, 1995; Kuyken, Padesky, & Dudley, 2009; Ramsay & Rostain, 2003). As such, the conceptualization provides a framework that helps a clinician to clarify, organize, and prioritize the various clinical issues for which patients seek help, including cognitive, emotional, behavioral, and developmental factors. For some individuals with ADHD, particularly with uncomplicated cases, the conceptualization is straightforward—treatment involves learning and implementing coping strategies for ADHD and navigating through some typical barriers to follow-through. With cases of increasing complexity, typified by increased number or severity of problems (or both), there are often multiple factors at play that influence attitudes about the prospect of change as well as one’s self-image, comorbidity patterns, and issues related to emotional management. The case conceptualization framework helps clinicians and patients to “think like a

Downloaded by [New York University] at 12:14 14 August 2016 cognitive behavioral therapist.” In addition to guiding the treatment plan and selection of interventions, this conceptualization provides clinicians with a way to make sense of the myriad clinical issues that may arise in the course of CBT. When treating adults with ADHD, there are many permutations of symptom clusters and executive dysfunction/ motivational deficit profiles, along with reciprocal interactions of these profiles in specific contexts that create the functional impairments for which individuals seeks help. Even though ADHD is not environmentally caused, it is environmentally bound insofar as its effects can be best understood by how they manifest in a particular context. One element of CBT for adult ADHD that is different from traditional CBT is the role the disorder plays in patients’ daily lives. The symptoms, executive function profile, and motivational issues are factored into the case conceptualization and undergird the Models of Treatment 49 psycho-education component of treatment, which provides patients with a mental scaffolding for understanding the source of their recurring coping difficulties. Once defined, patients have a reference point for identifying their ADHD in action, which allows coping strategies to be introduced as a counterpoint. The executive dysfunction model of ADHD provides a framework with which to “reverse engineer” specific impairments of daily life. That is, this process helps patients understand the multiple executive processes that may underlie an issue such as procrastination. It does not yield a profile akin to that provided by, say, the Meyers-Briggs Type Inventory, but understanding the relative strength and weaknesses in the different domains of the executive functions, including self-motivation (e.g., Barkley, 2011b; Kes- sler et al., 2010) offers a good clinical baseline. Using the executive function framework allows patients to “see” their time management or motivation difficulties in more concrete terms. By providing a template for how these seemingly uncontrollable difficulties arise, individuals are able to break down these difficulties into the component steps, which become the targets for intervention in CBT. For example, James cited difficulties with procrastination, noting that he “always feels busy but never seems to get things done.” His scores on an inventory of executive functioning (Barkley, 2011b) indicated poor time management, poor organization and problem solving, and poor motivation. Psycho-education entailed using these findings to help James understand how ADHD affects his ability to engage in and complete a task until it is “done.” James and his therapist identified a specific example when he did not complete what he defined as a priority task. A behavioral analysis of this specific example involved a detailed review from the point at which James was “on task” to the point at which he realized he was “off task.” This process involved “reverse engineering” from the point at which he recognized he was off task back to the point at which distraction occurred so as to determine any antecedents that set the stage for distraction. Information regarding James’s internal experience at various pivot points (“What thoughts were going through your mind? What were you feeling? What was it like to be ‘in your skin’ at that moment? How did you justify getting off task at the time?”) and behavioral actions (“What did you do then? Where did you go?) help to shed light on a procrastination sequence or “script” that is rooted in ADHD but that has been strengthened by negative reinforcement associated with escape from a task. This level of assessment and understanding provides the clinician and patient with a more nuanced understanding of the network of issues that make it difficult for James and other people with ADHD to follow through on plans.

Downloaded by [New York University] at 12:14 14 August 2016 Moreover, the emphasis of real-life examples provides personally relevant targets for treatment. Although psycho-education is not focused on changing the pattern, being able to see the pattern as a discrete set of behaviors helps to formulate an alternative pattern. It also redefines past difficulties and sets the stage for change. That is, when discussing a later example of getting off task, James reported, “I knew that I was procrastinating when I clicked on my favorite website rather than opening the document I wanted to work on, telling myself, ‘I’ll just check it for a minute or two,’ but I still did it anyway instead of doing work.” Even though he succumbed to procrastination, there now is a more detailed and informative understanding (or meta-understanding) of the process. Said differently, James was better able to “see” his procrastination. In turn, this understanding coupled 50 Models of Treatment with coping strategies for better handling crucial junctures in the sequence increases the likelihood of adaptive outcomes. Another dimension through which our conceptualization of ADHD and our treatment approach has been fleshed out in the past few years is the growing recognition of emotional self-regulation as a distinct executive function (Barkley, 2010, 2011b; Kessler et al., 2010). ADHD is now understood as a disorder of self-regulation associated with underlying executive dysfunction and motivation deficits. Negative expressions of emotion were once alluded to in terms of “poor frustration tolerance” and as manifestations of impulsivity. Recent conceptualizations, however, have shed new light on the disruptive role of deficient emotional self-regulation (DESR) in the lives of adults with ADHD (Barkley, 2010; Surman et al., 2011). In an early description of our CBT approach for adult ADHD (Ramsay & Rostain, 2003), we wondered if the benefit of psychosocial treatment stemmed from relieving the “secondary distress” (i.e., emotional frustration) associated with ADHD in order to improve patients’ capacities to focus on the management of ADHD. Interventions addressing emotional dysregulation can now be considered central to the treatment of ADHD for many adults seen in practice settings. The case conceptualization is not designed to be stored in therapists’ heads but rather to be shared and discussed collaboratively with patients, both in terms of the relevant cognitive factors (beliefs, thought processes) and related behaviors (compensatory strategies, manifestations of executive dysfunction) that are most salient to them. This conceptualization gives the patient a template for understanding, identifying, and ultimately changing behavior patterns. For example, James, whose struggles with procrastination were outlined above, came to see that in addition to vulnerabilities from ADHD, he has a sense of “inadequacy” about his work performance. He doubts that the quality of his work is up to par, which contributes to his ambivalence about getting started on it. His frustrations at work are all too similar to his history of difficulties throughout school where he obtained negative feedback on his performance and effort. Thus, he experiences uncomfortable emotions when facing his work, reactions that increase his distractibility and discomfort. He escapes this discomfort by becoming “busy” with another, lower-priority task, fueled by rationalization cognitions (e.g., “I’ll get this out of the way and THEN I will be able to focus on the project for work.”) that became ultimately self-defeating. The case conceptualization is an evolving formulation that is revised as new information comes to light, and as individuals modify their self-view based on an improved ability to manage ADHD. Moreover, individuals inevitably face new challenges and

Downloaded by [New York University] at 12:14 14 August 2016 endeavors as they make progress in treatment. These challenges provide them with novel experiences that build on an evolving sense of self. The ultimate goal is to have patients become their own therapists and to be proactive in the long-term management of ADHD and personal well-being. We will discuss the different components of the CBT case conceptualization for adult ADHD below (see Figure 2.1 ).

Neurobiology and Environment Interaction Our CBT conceptualization of adult ADHD begins with the awareness that ADHD is a highly heritable neurodevelopmental disorder of impaired executive functions and associated motivational deficits that influences one’s life experiences from a very early age. Models of Treatment 51

Environmental context ADHD neurobiology Executive Dysfunction Motivational deficits

Developmental experiences Underdeveloped coping skills

Chronic difficulties

Coexisting conditions Impairments

Schema/Core beliefs Compensatory strategies

Current situation

Cognitions Emotions Behaviors

Figure 2.1 Diagram of the Cognitive Behavioral Case Conceptualization of Adult ADHD

Even if the initial manifestations of the syndrome are relatively mild and are not diagnosed until later in life, these effects likely play an influential role in situations and relationships encountered throughout one’s life, due to the impact ADHD has on various aspects of attention, cognitive and emotional management, and self-regulation. At some point in their lives, most individuals with ADHD describe coming to a realization that certain tasks or situations are more challenging for them than they are for others and/or that they “do things differently than other people.” This insight may occur at a young age for some individuals, such as the man who remembered being “expelled” from preschool. Or it may arise later in life, such as the 40-year-old man who feels “stuck” in his life and recognizes that his recurring experience of “starting over” represents a longstanding problem of not being able to follow through rather than of a need for variety. Even when the recognition of differences occurs later in life, understanding past

Downloaded by [New York University] at 12:14 14 August 2016 functioning through the “lens” of ADHD provides patients with an enhanced view of their difficulties with motivation, disorganization, procrastination, etc. ADHD symptoms and impaired executive functions can affect the various internal and external events or stimuli to which an individual selectively pays attention to the exclusion of others. Said in a less technical way, we all sort through a variety of experiences and relationships in order to figure out the rules for how the world works and how to define our place in it. This sort of selective focus, through a combination of temperament and context (i.e., nature and nurture), has implications for one’s life course including making choices that affect one’s sense of self and identity (e.g., such as academic interests, perceived areas of competence, job/career selection, managing relationships and family, physical well-being). In this way, ADHD affects one’s sense of identity 52 Models of Treatment through these choices, experiences, and outcomes across various endeavors throughout life. This view is congruent with the model of executive functions that emphasizes how ADHD interferes with the pursuit of personally relevant goals that have long-range effects on well-being (Barkley, 2012). It is not surprising that the college-age years of young adulthood are when many adults with ADHD are first identified. This time of “emerging adulthood” (Arnett, 2000) is the period for assuming adult roles that require intact executive functioning to fulfill and that are influential in one’s sense of self. There may be signs and symptoms of ADHD present before young adulthood but that does not affect the trajectory to the degree that the person is knocked “off course” until facing the demands of adult life. Hence, it makes increasing sense that ADHD in adolescence has emerged as an important predictor of long-term impairment, even more than childhood ADHD (Brook, Brook, Zhang, Seltzer, & Finch, 2013; Klein et al., 2012). At the same time, adolescents at risk for ADHD—or, more accurately, who exhibit features of ADHD not yet identified as such—are most likely to fall through the cracks inasmuch as there is a drop off of identification in the teenage years (Biederman et al., 2006) .

Developmental Experiences Because CBT is known as a “here-and-now” therapy approach, focused on measurable and observable symptom improvement and behavior change, it is often wrongly assumed that CBT does not place much emphasis on developmental experiences. On the contrary, these experiences are crucially important as they provide the raw material from which our deepest-held beliefs are formed. When discussing the CBT model for and conceptualization of adult ADHD, these developmental experiences have a twofold, interrelated importance. First, the case conceptualization provides a framework for understanding the effects of ADHD on experiences throughout the different stages of an individual’s development. This facet of the conceptualization allows for a biographical understanding of an individual’s experience of ADHD in context and its effects on one’s life. Second, this developmental information sheds light on how the patient made sense of these experiences in terms of attitudes, beliefs, and personal rules while dealing with ongoing executive dysfunction and motivational deficits through different stages in life. Growing up with ADHD affects how individuals interact with their worlds and how they handle various demands in life. That is, there is reciprocal influence between a per-

Downloaded by [New York University] at 12:14 14 August 2016 son with ADHD and the surrounding environment, with each recursively feeding back on and affecting the other. The difficulties associated with ADHD lead to frustrations in various aspects of life that affect how individuals make sense of themselves and their place in the world. Of course, not all developmental experiences for individuals with ADHD are negative. There may be interactions with supportive family or teachers and activities (e.g., sports, art) in which an individual thrived. Special skills and aptitudes also can be discovered or identified and cultivated. Moreover, some individuals develop and maintain healthy, adaptive attitudes and simply seek treatment in adulthood to help them to learn to cope better, presenting with little, if any, psychological “baggage.” However, a diagnosis of ADHD, particularly among clinic-referred adults, is often associated with many Models of Treatment 53 interpersonal, academic, and vocational problems that affect the areas of life from which we get our sense of belonging and competence. These experiences are clinically informative as research has indicated that adults with ADHD recall having more difficulties and negative experiences in childhood than individuals without ADHD (Biederman et al., 2006). Thus, it is important to recognize the often damaging effects of these experiences, when applicable.

Schema and Core Beliefs The terms schema and core beliefs are often used interchangeably in the CBT literature but are technically different (J. S. Beck, 1995; Young, 1999; Young, Klosko, & Weishaar, 2003). Schemas are cognitive structures or mental categories for assessing and interpret- ing the various stimuli that we encounter in life. There is a basic human propensity to make coherent sense of and find meaning in experience. This tendency has survival value because it allows people to catalog experiences and to amass a fund of information about the environment. This fund of information helps us to evaluate and handle new situations we encounter, often with the goal to avoid physical and/or emotional pain. Thus, schemas are primarily influenced by our developmental learning experiences. Schemas can be thought of as CBT’s version of Freud’s notion of the unconscious because they operate nonconsciously and represent our absolute, unquestioned sense of how the world is and how it operates, including issues related to self-definition and identity. The different schema domains reflect categories of human experience, including disconnection and rejection, impaired autonomy and performance, impaired limits, other-directedness, and overvigilance and inhibition that help orient us to “how the world works” (Young, 1999). Schemas can be likened to the lenses through which we view the world. If someone peers through clear lenses and sees a small, slightly oblong yellow-skinned fruit, the person will quickly identify it as a lemon. However, if that same fruit is viewed through blue lenses, the same person will quickly identify the fruit incor- rectly as a lime despite it still being a lemon. Thus, our schemas significantly influence how we view the world and consequently, our functioning. Schemas have been found to exert influence on behavior as early as 8 years old (Taylor & Ingram, 1999), though they do not consolidate until adolescence (Hammen & Zupan, 1984). It should be noted that it is around the age of 8 when the privatization of verbal working memory occurs, meaning that self-talk (i.e., cognitions) becomes covert and increasingly starts to guide personal behavior (Barkley, 1997).

Downloaded by [New York University] at 12:14 14 August 2016 If schemas represent the common buckets that are used to organize experience, the core beliefs represent the personalized experiences that we each place in those buckets. Core beliefs are the specific expressions of these schematic domains in the form of rules or conditional statements (e.g., if-then) that are relevant and meaningful to individual patients in their daily lives as well as being related to their overarching sense of self. Hypotheses about potentially relevant schema can be formulated by observing how beliefs seem to cluster around the particular schematic themes or domains. Because these schemas and beliefs are the result of personal experiences, they exert influence on behaviors, a significant category of these behaviors being the compensatory strategies, which we discuss next. From a clinical standpoint, helping patients to recognize situations that activate particular maladaptive reactions, often including strong emotions, is 54 Models of Treatment a good coping strategy. Simply recognizing when she or he is “in” such a situation can interrupt a pattern of dysregulation, akin to Woody Allen’s character in the movie Hus- bands and Wives , who found himself in a compromising situation and said, “Right now I’m feeling $30,000 of psychoanalysis dialing 9-1-1.” It should be noted that healthy, adaptive schema and core beliefs also exist and play an important role in resilience and positive well-being. In fact, these outlooks and associated experiences can be accessed and used to foster adaptive coping. However, our focus here is to shed light on some of the maladaptive schema and beliefs we have identified in adult ADHD patients that undermine their well-being in the form of self- defeating behaviors, as we discuss in the next section (see Table 2.1).

Compensatory Strategies Compensatory strategies represent a crucial component of the CBT conceptualization and are an important level for therapeutic intervention. These behaviors should not be confused with compensations that are often discussed in the ADHD literature. Compen- sations refer to the ways individuals with ADHD learn to cope with and minimize the effects of the symptoms (Hallowell & Ratey, 1994). So, for example, an individual with ADHD who regularly forgets to follow through when he has promised to do something for a coworker learns to compensate by asking the person making the request to send a follow-up e-mail reminder with specifics about the request. Compensations are viewed as positive coping efforts, though they may be vulnerable to disruptions, such as if the individual mentioned above deletes the e-mail reminder before transferring the promised task to his to-do list (or does not regularly check that e-mail account) and subsequently forgets about it. Compensatory strategies in the CBT model, on the other hand, refer to the efforts to address the schema and core beliefs that seem at first blush to be adaptive, but which ultimately and insidiously maintain and reinforce maladaptive beliefs. They can also be thought of as self-defeating behaviors. Procrastination and avoidance is the most common compensatory strategy we have observed in adults with ADHD. Although it starts as a manifestation of executive dysfunction, it is later magnified by maladaptive reactions to and avoidance of difficult situations. Of course, ADHD makes many aspects of adult life difficult to manage; hence many situations are ripe for avoidance. Similarly,

Table 2.1 Common Schema and Core Beliefs Observed in Adult ADHD Patients Downloaded by [New York University] at 12:14 14 August 2016 • Self-mistrust—“I cannot rely on myself to do what I need to do. I let myself and others down.” • Failure—“I have not met expectations. I always have failed and always will fail at what I set out to do.” • Incompetence/Inadequacy—“I am too inept to handle the basic demands of life.” • Defectiveness—“I’m basically a bad, flawed person.” • Instability—“My life will always be chaotic and in turmoil.” • Unlovability/Social Exclusion—“No one will ever want to put up with me over the long run,” or “People will reject me.”

Drawn from Ramsay and Rostain (2003) and Young and Klosko (1994). Models of Treatment 55 Table 2.2 Common Compensatory Strategies Observed in Adults with ADHD

• Anticipatory avoidance/Procrastination—Magnifying the difficulty of a pending task and doubting one’s ability to complete it; results in rationalizations to justify procrastination behavior • Brinksmanship—The tendency to wait until the last moment to complete a task, often when compelled to do so by an impending deadline. • Juggling—Taking on new, exciting projects and feeling “busy and productive” without making progress on projects already started. • Pseudoefficiency—Completing several low-priority, manageable tasks (e.g., checking e-mail, cleaning desk) but avoiding high-priority, challenging tasks (e.g., complete report for work). • Stoicism—Impassively accepting one’s circumstances due to excessive pessimism about the prospect of making desired changes in life.

Drawn from Ramsay and Rostain (2003) and Rostain and Ramsay (2006a).

unmodulated anger at others and excessive externalization of responsibility are other compensatory patterns that develop as a defense to manage the activation of personal inadequacy. This approach works in the short-term, at least getting the person out of the immediate situation, but is ultimately ineffective and self-defeating, magnifying the sense of inadequacy (see Table 2.2). For example, John is a college student who earned solid grades through high school but said that he could have performed better. His grade point average likely kept him from gaining admission to some of his top choice colleges, a fact that was embarrassing to him and raised questions for him regarding whether he was a “good student.” John described various times when he harbored doubts about his intelligence due to problems with schoolwork, which were later understood as related to undiagnosed ADHD. He relied upon making up excuses to get extensions on larger assignments, hoping that teachers would forgive and/or forget missing homework, and, at times, cheating. John was admitted to a reputable college and started his first semester. He experienced some difficulties managing life on campus away from the structure of the family home. After a few weeks, he grew intimidated and somewhat overwhelmed by the increased amount and difficulty of work compared with high school, which activated his hibernating schema of “inadequacy,” in the form of the core belief, “I am not as smart as everyone else.” John did not recognize that he had not adjusted his approach to his academic work from when he was in high school in order to accommodate the demands of the new

Downloaded by [New York University] at 12:14 14 August 2016 environment. In fact, it could be said that he did not realize that there was any other way to handle academics than what he had always done. Hence, he attributed his struggles as evidence of his inadequacy, rather than as a consequence of his study habits, which could be changed. During a CBT session, John reported that he failed two classes the previous day and had “ruined (his) future.” He clarified that he skipped an 11 a.m. Economics class earlier in the day in order to work on a paper for his English Literature class that was due at 5 p.m. that day. As presented, it was a feasible (though not ideal) problem-solving option—skip a class to complete an assignment due for another class by the deadline. However, at noon he realized that his absence from his morning class meant he had exceeded the allowable number of class absences for the Economics class, the consequence 56 Models of Treatment of which was automatic failure for the class according to school guidelines. Consequently, he said that he was too upset to be able to concentrate on finishing the paper and he did not bother submitting it, assuming he would receive a grade of “zero” and fail the Litera- ture class, too. There was some basis for John’s concerns—he missed the deadline for submitting the assignment and, in fact, he had violated the attendance policy in his other class. We reviewed his problem-solving options, most notably contacting his professors, explaining the situation in a forthright manner, and getting accurate information about his options. However, when reviewing worst-case scenarios, we identified that he could still drop the Literature course without failing it for the semester. While not his ideal scenario, it was preferable to failing. We also reviewed the fact that failing one course need not ruin one’s life, though acknowledging it can be upsetting. This led to the review of his thoughts about the situation and the activation of his negative beliefs. John, in fact, followed up with these suggestions and contacted the professors for each course (overcoming his negative assumptions about doing so), and the Literature professor granted him a deadline extension, though imposing a half letter grade penalty. The Economics professor agreed to excuse the most recent absence, though required that John make up the class by attending another section of it that was offered later that week. It should be noted that had John not contacted his professors, his anticipated scenario of failing the courses would have occurred and, although not resulting in the worst-case scenario (i.e., “My life will be ruined”), the outcome would have been seen by him as further evidence supporting his negative self-view and would have required even more therapeutic effort to modify. As seen in this example, compensatory strategies provide a useful means for eliciting relevant schema and core beliefs, in large part due to the strong emotions attached to the activating situations. In fact, the conceptualization is often constructed from the inside- out, starting with the compensatory strategies. That is, specific behavioral examples of coping difficulties are elicited during the discussion of treatment goals and targets for intervention. Information regarding in-the-moment experience of these situations (e.g., thoughts, feelings, and behaviors) as well as past experiences (e.g., “In what other situations do you notice this difficulty? Does it remind you of similar difficulties you experienced in the past? What were the outcomes then?”) situate the specific difficulty within a larger pattern of coping. In many cases of uncomplicated ADHD, the coping difficulty is the primary source of frustration and may be associated with similar difficulties in the past, but with minimal effects on sense of self. However, more complex cases may involve

Downloaded by [New York University] at 12:14 14 August 2016 more complicated interactions of a variety of factors affecting management of ADHD, most notably a preponderance of self-defeating behaviors including inconsistent follow- through with treatment. Compensatory strategies also provide obvious targets for behavior change. In John’s case, he admitted that he got by in high school, in large part, by putting off work until the last minute or by simply not doing it. Consequently, the prospect of facing college- level work activated both anxiety and a deep sense of inadequacy. An early coping target in CBT involved breaking down larger class assignments into their component steps and devoting reasonable blocks of study time to focus on them. Although this is a common CBT intervention for adult ADHD, for John it also addressed a pattern of avoidance connected with his negative sense of self. Models of Treatment 57 CBT emphasizes the use of specific situations in order to gain important information about the in-the-moment experience of individuals at the point of performance. The clinically relevant information includes their automatic thoughts, emotions, and behavioral responses that help the clinician to see the world “through the patients’ eyes.”

Automatic Thoughts, Emotions, and Behaviors Perhaps the defining feature of CBT in comparison with other models of psychotherapy is the emphasis on the influential role cognitions have on personal experience and functioning. That is, the manner in which events are interpreted, before, during, and after the actual event, have important and cascading effects on emotional reactions, behavioral responses, and subsequent cognitions. The concept of automatic thoughts, those fleeting thoughts or images interposed between an event and our reaction to it, helps individuals to recognize and encapsulate their distorted assumptions that have effects on functioning. Automatic thoughts occur quickly and just out of awareness though they are easily recognized when someone is alerted to their importance. They are akin to Freud’s notion of the preconscious. These thoughts often go unquestioned because they are embedded within the steady stream of thoughts, images, and other cognitions. Most of our thoughts are emotionally neutral. However, because cognitions occur rapidly and are often unquestioned, they can easily be distorted or erroneous (i.e., based on incomplete information). This is particularly the case when a situation is meaningful to an individual and runs the risk of activating a schema or mobilizing strong emotions. For example, two coworkers pass in the hall, and one says hello, but the other person walks by without responding. The one who offered an unrequited greeting might think, “She must not have heard me” and is unaffected by the interaction. However, if the automatic thought in that situation is, “She ignored me on purpose,” the individual might feel anger at being “ignored.” Left unchallenged, these automatic thoughts have the potential to alter mood, behavior, and subsequent cognitions in what can be a very vicious cycle. Emotions and reflexive actions (i.e., impulsivity) sometimes precede higher-order cognitive processing, such as in the case of sympathetic nervous system arousal in response to seeing a snake (or a garden hose at first glance thought to be a snake). How- ever, thoughts often play an influential role in mood shifts and behavioral choices, and they are always involved in how we make sense of experience. Even in the case of impulsive behaviors, it is often the “after-the-fact” realization that one’s behavior was ill-

Downloaded by [New York University] at 12:14 14 August 2016 advised that contributes to the lingering feelings of guilt, negative thoughts, and self-criticism frequently reported by individuals with ADHD. Adults with ADHD may describe the absence of thoughts in a situation that, in retrospect, they can see called for a reaction. There are times when ADHD adults’ negative thoughts, or at least their assessment of adverse events, are not cognitive distortions but, instead, reflect accurate interpretations of mistakes or undesirable outcomes. For example, Bill, a man with ADHD who struggles with time management and disorganization, forgot to pick up his wife’s dry cleaning, which included the business suit she wanted to wear to a job interview the next day. She had to leave for the interview before the dry cleaner opened the next day, so she had no other recourse but to wear something else. Bill’s initial automatic thoughts in response 58 Models of Treatment to recognizing his error, “I messed up and forgot to pick up the dry cleaning” and “My wife will not be able to wear her favorite suit,” were accurate characterizations of the situation. However, because such situations are common for adults with ADHD, secondary automatic thoughts often result in conclusions that go beyond the experience of the actual situation, such as Bill’s reactions that, “I’m such a loser. My wife cannot count on me for anything. She would be better off without me.” Bill experienced a quick and notable shift in his mood, illustrating how emotions can be distracting to and difficult to manage for adults with ADHD. Bill ended up not being able to focus on some tasks he had to do for work (e.g., “I cannot focus when I am upset.”), which compounded his coping efforts. The point is that although the foundational coping difficulties encountered by adults with ADHD stem from executive dysfunction, their cognitive reactions (and emotional reactions, by extension) play a role in their experiences and, subsequently, in attempts to cope. CBT is not about the “power of positive thinking” but rather about the power of “adaptive” thinking. For example, compulsive gamblers’ positive thoughts often are not adaptive. There can be a “positive bias” in cases of ADHD in which individuals minimize signs of trouble, deflecting concern with the optimistic view that “things will work out” without taking proactive steps to manage a situation. As one of our patients stated when his therapist expressed concerns about risks the patient seemed to minimize, “I know I should be worried about what could happen, but my problem is I am not worried enough.” This example can be considered the other end of the continuum of DESR— being “underwhelmed” by adaptive levels of uncomfortable emotional information, such as appropriate levels of worry. Adaptive thinking allows individuals to strike a balance between accepting things that cannot be changed, being resilient in exerting their influence on things within their control, and considering all possibilities regarding what can be changed, akin to Reinhold Niebuhr’s iconic Serenity Prayer. Such cognitive flexibility is a hallmark of problem solving and creativity, with both of these skills being among those that are compromised by executive dysfunction. In Bill’s case above, he eventually acknowledged that he could not undo the fact he forgot to pick up his wife’s dry cleaning, recognized that his wife had other perfectly fine business suits, and realized that his gaffe would not affect her interview. He also acknowledged that his importance to his wife and family extended beyond this single (though not uncommon) mistake. Bill was able to see that if he waited to “be in the mood to work” or for conditions to be ideal, he would not get much done. Bill got back on track

Downloaded by [New York University] at 12:14 14 August 2016 by defining a small, specific work task to do in order to get started, finding he got reasonably engaged after a few minutes, which also served as an emotional distraction. While he was not happy about his mistake, Bill learned that he did not have to let a mistake needlessly ruin his evening or interfere with his relationships. As a case conceptualization evolves, even apparently self-defeating behaviors “make perfect sense,” not only in light of our understanding of the effects of ADHD, but also through eliciting the reactions and personal meanings attributed to past experiences. In the case of John, the college student who worried he had failed two classes in 1 day, when considering his simmering difficulties in high school, it was no surprise that he faced problems in college and had an escalation of his sense of inadequacy. Similarly, Bill was able to see that his mistake of forgetting his wife’s dry cleaning was not catastrophic, but it made Models of Treatment 59 sense that it activated a strong emotional reaction because it reminded him of a pattern of similar mistakes that left his feeling defective despite his many positive qualities. Progress in CBT requires being able to approach and manage situations differently, including developing new outlooks on them, and being willing to experiment with new behaviors and skills. In cases of mild ADHD, individuals often possess generally adaptive outlooks apart from circumscribed problems related to ADHD. In these cases, the conceptualization is usually clear-cut and uncomplicated, and CBT is devoted to implementing straightforward coping skills. However, in cases of moderate to severe ADHD, particularly when there are coexisting diagnoses and complex developmental histories, the case conceptualization is pertinent because there is greater likelihood that negative beliefs, compensatory strategies, and other complications will influence the clinical picture. Moreover, these factors will interfere with the follow-through required to face challenging situations and utilize coping strategies, thereby raising the risk for dropping out of treatment. The next section focuses on the delivery of CBT for adult ADHD.

CBT for Adult ADHD in Clinical Practice

Development of the PENN CBT for Adult ADHD Model Before reviewing the components of our CBT approach for the treatment of ADHD, we should put our approach into context. The first edition of this book as well as this revised edition represent our “treatment manual,” although it differs in its development and format from other existing CBT treatment manuals for adult ADHD (e.g., Hesslinger, Philipsen, & Richter, 2004; Safren et al., 2005; Solanto, 2011; Young & Bramham, 2012), all of which we regard to the utmost and recommend without reservation. As a treatment approach is developed, a collection of effective interventions is defined and sorted into different treatment modules that provide the framework for individual sessions. These interventions are drawn from clinical experience and honed through working with patients—a process of informal pilot testing to determine what is helpful and what is less helpful. A reasonable number of sessions and corresponding session modules or topics are defined in order to provide an adequate “dose” of psychosocial treatment. The modularized treatment is used in clinical practice to determine if it is useful, pilot tested in smaller studies, and ideally subjected to a randomized controlled study in which it is compared with another active treatment. This has been the case with several effective CBT approaches for adult ADHD, which are reviewed in Chapter 3 .

Downloaded by [New York University] at 12:14 14 August 2016 The development of our treatment model followed a somewhat different path. We designed our approach from our clinical work in an adult ADHD specialty treatment program. Our conceptualization and interventions were developed through extensive clinical assessment of what worked and what did not, eventually becoming organized into a treatment program, akin to the informal pilot testing mentioned above. However, rather than defining specific modules and a session-by-session manual, because our clinical population includes a degree of clinical complexity associated with a high degree of impairment and/or comorbidity profile, we chose to adopt an individualized conceptualization based approach. In this way, we were able to link different profiles in our patients to the coping skills most beneficial to their unique needs. Although drawing from a similar and overlapping pool of coping domains and interventions as our 60 Models of Treatment colleagues, and drawing on specific “modules” for various coping skills (such as planning, organizational skills, dealing with procrastination, etc.), our model has not been studied as a modular using a defined sequence of sessions and session topics. The studies conducted on our treatment approach that comprise the evidence supporting this model are based on the administration of a personalized treatment package of roughly 16 sessions over about 6 months (Ramsay & Rostain, 2011; Rostain & Ram- say, 2006c). In some ways, the calendar time across which CBT occurs may be more important than the number of sessions because it requires time for adults with ADHD to become familiar with and to consistently implement new coping skills before their effects on life outcomes can be observed. Psychosocial treatment for adult ADHD is more similar to adhering to an exercise regimen in order to improve athletic performance than it is to taking a performance-enhancing drug. That is, exercise yields progressive benefits that can be observed and quantified, but the end points of a particular health measure (i.e., lowered cholesterol) or performance outcome (i.e., ability to run a certain distance) require persistent effort to achieve and maintain. That being said, one of the opportunities provided by this edition of the book (and the companion workbook) is to elaborate on the specific coping skills and strategies that are used to manage the effects of ADHD. These discussions represent our “modules” and provide explicit guidance for practitioners to help patients consistently implement these skills in their daily lives. Although CBT is personalized to each individual with ADHD, there is a pool of coping skills that represent the essential strategies for managing executive dysfunction associated with adult ADHD. In fact, there is a great deal of overlap and agreement about the essential coping strategies among the different psychosocial treatment programs for adult ADHD that have been independently developed by the different programs. The following sections provide an overview of various components of our CBT approach. The first few sections address general issues clinicians often encounter when starting treatment with adults with ADHD, particularly those who are newly diagnosed. Several of these are not unique to CBT nor to the treatment of ADHD, such as the importance of the therapeutic alliance; however, we emphasize how these therapeutic components are adapted to the distinct needs of adults with ADHD. Likewise, some of these sections herein are not emphasized in traditional CBT, such as dealing with one’s diagnosis, but they have special relevance for adults with ADHD. Our overarching goal is to help our patients cope more effectively with the problems they encounter as a result of having ADHD and its underlying executive dysfunction and motivational deficits. We

Downloaded by [New York University] at 12:14 14 August 2016 have elaborated on many of the specific coping strategies in this edition of the book. The companion workbook provides even more detail on the implementation of these strategies, managing the various barriers to their use, and adapting them to different situations and adult roles. The workbook is written as a user-friendly resource for patients but can be easily adapted by clinicians who treat adults with ADHD.

Reactions to the Diagnosis of ADHD Patients often express a sense of relief at learning their chronic difficulties fit the ADHD symptom profile and that there is a coherent and nonblaming explanation of the chief source of many of their struggles. Some patients are moved to tears as they gain an Models of Treatment 61 emergent understanding of how their longstanding troubles make sense as a consequence of having lived with undiagnosed ADHD, at times expressing anger that these issues were not identified earlier. Others experience a complex grief reaction in which they mourn the loss of possible life goals they failed to achieve. Still other patients describe going through the full array of reactions described above. Regardless of the reaction, an accurate diagnosis provides the first cognitive change intervention insofar as it offers an adaptive and accurate reframe for understanding their difficulties. To this point in their lives, most patients have viewed their difficulties as evidence of character flaws (e.g., “I’m lazy” or “I’m stupid”). Many patients are further heartened to learn that they are not alone in their struggles, that there is hope for change, expressing a strong motivation to get started with treatment immediately. By contrast, some patients remain skeptical of the diagnosis, such as college-aged individuals who are facing individuation and adulthood transition issues (Ramsay & Rostain, 2006; Rostain & Ramsay, 2006b). These young adults might be overwhelmed by the unwelcome notion that ADHD is affecting their various life pursuits. Others in this age group acknowledge the presence of ADHD but express a desire to “handle it on (their) own” rather than pursuing treatment. Many will express a genuine recognition of the need for treatment and other supports but then do not consistently make use of these services. They may require more time and further discussion before taking the diagnosis seriously. An increasingly encountered group in our practice has been partners in marriages or other committed relationships in which there is discord. In some cases, the partners undergoing the diagnostic evaluation identify that their lack of follow-through in the relationship is at odds with their desire to maintain the relationship. In other cases, a frustrated partner presses for an evaluation and treatment for ADHD as a potential solution for relationship issues. Whether or not the presence of ADHD is identified in one or both partners, dealing with the relationship dynamics adds a degree of difficulty to assessment and treatment (Ramsay, in press). Another group with an emotional reaction to the diagnosis is parents of young adults with ADHD. For college students and other young adults newly identified with ADHD, parents may berate themselves for not having recognized and sought help for what, in retrospect, seemed to be obvious signs of ADHD. Very often these parents report that a period of difficulty that raised concerns about potential ADHD in adolescence was followed by a period of generally adequate functioning that did not seem to necessitate taking action. It is often a major transition, such as to college or into the workplace that

Downloaded by [New York University] at 12:14 14 August 2016 reveals obvious and sustained levels of impairment. In rare cases, there is parental denial or at least underreporting of childhood difficulties on observer rating scales despite other corroborative sources (e.g., school reports, record of misconduct). The explanation can be that difficulties were not observed at home, though in some cases, there might be guilt about not having sought help earlier. At times, there is antipathy to the notion of ADHD and its treatment options from strongly held beliefs. For a notable minority of patients, the ADHD diagnosis triggers profound feelings of grief as they replay in their minds the many frustrations and lost opportunities in their lives with the sobering realization that there was help available had they been diagnosed earlier in their lives. These reactions represent important issues to address in CBT. Grief issues require emotional processing and a “coming to terms” on the part of the patient. 62 Models of Treatment Accurate empathy on the part of the therapist is vital to help the patient metabolize these feelings. The purpose of this processing is to allow patients to gain a measure of acceptance of their circumstances, so as to adopt an understanding of their problems within the rubric of ADHD. This acceptance helps promote the commitment of the patient to engage in efforts to deal with their ADHD in the here-and-now. Many individuals also achieve this acceptance through the course of their psycho-education, reading about accounts of other adults with ADHD, and discussing the diagnosis with loved ones. A somewhat different reaction faced in clinical practice that deserves attention is the group of patients who pursue an evaluation for adult ADHD and for whom it is determined that their developmental profile and presentation is not consistent with ADHD. Moreover, there may be situations in which there are subthreshold features of ADHD, but it is determined that other factors or symptoms are the root of the presenting problems. In particular, parents of college students facing problems in school or partners in a frustrating relationship might hold out hope that these difficulties result from ADHD and can be treated only to learn that it is not the case. Regardless of the scenario, it is recommended that clinicians are transparent about their assessment of the clinical data and the resultant conclusions. This is achieved through a thorough review of the necessary components required to establish a diagnosis of ADHD (e.g., onset, persistence, impairment), explaining the symptoms criteria for ADHD and executive functions, and collaboratively reviewing the clinical information gathered during the evaluation. This approach usually provides sufficient justification for the conclusions, helps the patient make sense of “what is going on,” and then leads to a discussion of helpful recommendations. The clinical reality is that not all individuals who seek or are referred for an evaluation for adult ADHD will have a developmental profile of emergence, persistence, and impairment consistent with the diagnosis. Thus, assessors must be able to provide such feedback in a constructive and forthright manner (see Ramsay, 2014).

Motivation and Readiness for Change Despite the heightened sense of clarity and insight about the effects of ADHD provided by an accurate diagnostic assessment, patients differ in their commitment to treatment. Time spent with patients reviewing expectations for or ambivalence about treatment is time well spent both to address and cultivate their motivation for participating in CBT, and to avoid repeating the frustrations they have likely encountered in past settings. ADHD and executive function problems make it difficult for individuals to organize

Downloaded by [New York University] at 12:14 14 August 2016 and sustain behavior across time toward a worthwhile long-range goal without short- term payoffs, or perhaps even incurring some discomfort at the outset. Moreover, motivation deficits by definition make it more difficult for adults with ADHD to engage in a coping plan despite the intellectual awareness that it will benefit them. Patients might also harbor doubts about the diagnosis, about their abilities to change what seem to be uncontrollable cognitive and behavioral impulses, and/or about some aspect of treatment (i.e., medications). Spending time addressing these issues using motivational interviewing and motivational enhancement approaches (Miller & Rollnick, 1991; Riggs, 2003) is very useful. Lay- ing out any motivational issues and matching CBT to the patient’s therapeutic pace can help to improve treatment compliance and outcomes. These discussions can address Models of Treatment 63 misunderstandings or misgivings about treatment in order to promote follow-through. On the other hand, some individuals may decide that they are not yet ready to commit to treatment. Either way, the goal is to help a person make an informed decision. (We discuss readiness for change in more detail in our discussion of complicating factors in Chapter 5 .)

Psycho-education Hearing the results of an assessment for ADHD, including personalized information about one’s executive functioning profile and its effects on daily life is an education for most patients. As mentioned earlier, this information may be revelatory for some newly diagnosed patients as they look back upon their past and review important life events in terms of the effects of ADHD. In addition to the self-awareness that accompanies the assessment process, explicitly providing psycho-education about ADHD to the patient is one of the critical first steps of treatment (Ramsay & Rostain, 2005a, 2005b, 2007). Its purpose is to demystify the diagnosis and its effects, and to correct misconceptions about ADHD and its treatment in order to facilitate follow-through on the coping strategies introduced in treatment. The clinical objective of psycho-education is to provide individuals with a personalized understanding of the role ADHD plays in their daily experiences so that they can start to “see” its effects. The therapist is a source of information for patients about their symptoms, descriptions of ADHD they have heard from friends or the media, and about treatment options. To encourage further self-knowledge, we also encourage patients to engage in personal research into ADHD, such as reading books about adult ADHD and exploring reputable online resources (see Appendix A). We caution that, while these resources can provide helpful information and can be useful adjuncts to treatment, they are not personalized to the patient’s unique circumstances. This caution is particularly relevant for patients with significant comorbidities and functional problems that are often beyond the purview of most self-help books and websites for ADHD. Indeed, the purpose of our personalized, combined treatment is to focus on the individual patient’s unique array of symptoms and strengths so as to develop an individually tailored treatment approach focused on specific treatment goals.

Defining Treatment Goals Downloaded by [New York University] at 12:14 14 August 2016 It might sound fundamental, but unclear treatment objectives lead to unclear treatment outcomes. This is not to say that the issues patients bring to therapy are always clear-cut and easily transformed into measurable therapeutic objectives. But there should always be discussion about and clarification of what the patient hopes to achieve in treatment. Agreed-upon objectives allow both the patient and the therapist to monitor the progress of CBT and make adjustments, as needed. Since the difficulties associated with ADHD are pervasive in patients’ lives, it is easy to set broad, imprecise therapy goals (e.g., “I want to procrastinate less,” “I want to be better organized,” or “I want to fulfill my potential.”). It is more prudent to identify specific problems encountered by patients in their day-to-day lives as a means to 64 Models of Treatment understand the effects of ADHD and explore new coping strategies (“Can you describe a time in the past week or so when procrastination or disorganization caused a problem for you? What was the situation and what happened?”). This strategy increases the likelihood that the therapist and patient start treatment on the same page. It also provides the therapist with specific, real-world examples of target problems. For example, a college student with ADHD might set a goal of earning an “A” in a particular class. This is a worthwhile aspiration but not a reasonable therapy goal. More reasonable therapy goals for the student might include improving class attendance from the previous semester, experimenting with sensible increments of time devoted to studying, adequate and advance preparation for exams/projects, and scheduling and keeping regular academic support meetings. Breaking down the original goal into this level of academic performance is more likely to yield clinically useful information, such as the student who observes, “I always start the semester attending all my classes but then something happens and I start missing too many.” The therapist can inquire about “what happens,” including the sequence of events that leads the student to miss the first class and how this leads to subsequent absences. In this way, a functional analysis of specific behaviors that are meaningful for the patient is vital to the development of useful therapy objectives. In addition to identifying adaptive coping targets, the reverse engineering of recent examples of coping difficulties also provides an opportunity to identify examples of how executive dysfunction maintains ineffective coping. Examples of the very sorts of compensatory strategies that were introduced in the discussion of the case conceptualization can actually end up being self-defeating for the patient. This can become an important initial focus of intervention. For example, Carly is a 39-year-old woman who is currently unemployed. She agreed with the notion that it would make good sense to use a Daily Planner to organize her schedule, including job-search efforts. However, she also had a core belief of “failure” and “self-mistrust” associated with the experience of making promises to herself and others that she did not keep consistently. Hence, the notion of writing down a commitment in a Daily Planner activated anxiety magnified by the worry that her husband or children would see her plans. Her thought was that “If they know what I am trying to do and I do not do it, they will know I failed and I will be letting them down.” Carly developed the rationalization that “I don’t like to be limited by a schedule,” pointing out some times she was able to make do without plans, though these times were rare. Her compensatory strategy was handling things spontaneously and having the self-view that she “just goes

Downloaded by [New York University] at 12:14 14 August 2016 with the flow.” When starting CBT, Carly tried to covertly keep a schedule and only write down some trivial tasks, leading to her frustration that she was not more productive and the conclusion that “The planner does not work” and “I cannot rely on myself and neither can anyone else.” A CBT session was devoted to helping Carly understand her cognitive and emotional reactions to the coping skill of using a Daily Planner, including the discomfort associated with trying something that she viewed as a “risk for failure.” However, helping her “see” the pattern allowed her to catch it when she was at risk for repeating it. She subsequently agreed to be more open with her family about using the planner rather than keeping it secret. Carly also developed adaptive reminders to help her remember to use the planner, to counter the assumption that she was being judged by others (e.g., “They are just Models of Treatment 65 curious and have my best interests in mind.”) and to offer general, nonspecific responses to their inquiries (e.g., “I’m still getting used to using it.”). Another common example of setting goals is when a patient states “I want to be better organized.” Again, this is a laudable and understandable goal, but, as worded, it does not yet provide a clear picture of how treatment should proceed. Asking for examples from the previous week when the patient’s disorganization proved problematic, or employing a prospective inquiry such as, “Two months from now, what would be a real-life example of being more organized that would signify to you that CBT was working?” will help the therapist and patient crystallize achievable outcomes. Patients’ answers usually spell out near-term, specific areas of difficulty that can serve as useful treatment objectives, such as keeping track of and paying the next month’s bills. On occasion, patients hesitate about mentioning a pressing goal for therapy or an agenda item for a session, stating “I’m not sure if this is an ADHD issue.” We immediately clarify that we consider any life problem or issue as fair game for “ADHD therapy.” Our rationale stems from the executive dysfunction/motivational deficit model of ADHD inasmuch as these play a pervasive role in patients’ developmental experiences, relationships, interactions with the world, and sense of self. ADHD affects issues such as relationship problems and career obstacles that some patients consider non-ADHD issues. Furthermore, considering that in a majority of adult ADHD cases there is at least one comorbid psychiatric diagnosis (not to mention other complicating factors such as medical issues, relationship problems, etc.), we do not want patients to feel limited in their freedom to raise “non-ADHD” concerns that might have implications for their overall well-being. For example, one patient had difficulties organizing herself and following through on appointments for a treatable medical condition in which there was a risk of escalating severity of symptoms the longer it went untreated. Securing and following through on medical treatment was listed as a priority of CBT for this individual, and planning and organization skills focused on the management of her medical condition were emphasized in treatment. Many patients have suffered in broad domains of adult life because their ADHD symptoms had not been acknowledged and treated. We do not want to make the same error by not respecting the long reach of ADHD into these other domains of well-being.

Therapeutic Alliance

Downloaded by [New York University] at 12:14 14 August 2016 The importance of the therapeutic relationship is ubiquitous in the psychotherapy literature (Horvath, 2001; Lambert & Barley, 2001). It is considered a common factor that influences the outcome of all different forms of psychotherapy. Although it has received less attention in the ADHD literature, the importance of providing the patient with a safe environment in which to explore the nature of his or her difficulties, to develop new coping skills, and to discuss the range of emotions involved in this personal undertaking cannot be overstated. The clinical consensus is that a therapist who works with adult ADHD patients cannot afford to adopt a passive role. Rather than being a blank slate, the therapist actively inquires about patients’ experiences, keeps sessions focused, and helps patients find a balance between accepting the effects of ADHD and working to make behavioral 66 Models of Treatment changes. This active therapeutic stance does not mean there is no room for creativity in sessions, but instead allows patients to receive valuable and timely behavioral feedback in a supportive context. For example, if the therapist observes that the session has devi- ated from the stated agenda, it is appropriate to provide feedback to the patient and to collaboratively make a decision about whether to refocus on the agenda or to revise the agenda to focus on the new topic (e.g., “I notice that we’ve gotten a bit off track from what you said you wanted to focus on today. Do we want to change our agenda for today or do we want to return to the original topic?”). Another common therapeutic issue is managing what would typically be deemed “therapy-interfering” behaviors. Tardiness to sessions or failure to complete therapeutic homework, actions traditionally thought to be signs of hostility or resistance, are better first considered as being generated by ADHD before assuming other dynamics are driving them. Framing these occurrences as opportunities to understand the effects of ADHD and to develop new coping strategies gently addresses both the core symptoms and the reactive defensiveness (or embarrassment) engendered by these sorts of recurring difficulties in a constructive, nonshaming way. In fact, it is often useful to predict that some or many of these sorts of behaviors will be encountered during the course of therapy and that they serve as “grist for the mill” in terms of ADHD issues. The primary benefit a positive therapeutic relationship provides to ADHD adults, however, is that it becomes a collaborative endeavor focused on managing the effects of ADHD. Adults with ADHD frequently describe feeling ashamed of their recurring difficulties and demoralized by the criticisms from others they have heard in the course of their lives. It is common for ADHD patients to assume that their psychotherapists will be upset with them if their therapeutic homework is inadequate, incomplete, or forgotten, or if they are not making sufficient progress in therapy. We often hear comments along the lines of, “You must be frustrated with me,” or “I bet no one else has this much trouble following through on homework.” It is natural for the therapeutic relationship to become a reenactment of the patient’s relationships outside of therapy. Indeed, these transference phenomena are highly prevalent. For example, a patient might assume that the therapist will be angry about slow progress or frequent tardiness for sessions. Consequently, the patient responds either by being particularly accommodating and apologetic (e.g., “I’m sorry I’m late. I’d understand it if you would want to reschedule. I don’t want you to think this is not important to me.”), or by trying to circumvent the therapist’s policies (e.g., “I know I’m a little late but can’t

Downloaded by [New York University] at 12:14 14 August 2016 we have a full session? This is what you’re supposed to be helping me with anyway, right?”) (e.g., Bemporad, 2001; Bemporad & Zambenedetti, 1996). Eliciting patients’ thoughts about their behavior and their assumptions of the therapist’s reactions (e.g., “Do you have any thoughts about what I might be thinking right now?”) help to foster a collaborative conceptualization of the situation. Thus, distorted thoughts about the therapist’s reaction can be modified and the session refocused on specific behavior strategies for avoiding similar problems in the future. These alliance building approaches also provide a pivot point to focus on addressing the real-world consequences of such behaviors (e.g., “I understand the difficulties you have arriving on time, and they provide us an opportunity to change them. I imagine that your boss is not going to be as understanding, however.”). This problem-focused approach creates a Models of Treatment 67 collaborative environment in which patients feel comfortable exploring and changing problematic behavior patterns.

Session Structure An immediate appeal of CBT approaches for adult ADHD is that sessions are more structured than in other psychotherapy models. While the degree of structure may differ among individuals with various treatment objectives, with some patients requiring more structure than others, there is a common framework to each session. Sessions generally start with a check-in of mood, current functioning, and a review of leftover issues from the previous meeting, including any relevant medication issues (e.g., compliance, side effects). Therapeutic homework from the previous session is reviewed. Homework compliance is an issue in CBT in general but even more so in the case of adult ADHD. However, when a patient has not completed a homework task, it is viewed as an opportunity to gather important information. Identifying the factors that result in such a task not being done is just as informative as reviewing the results of completed homework tasks (e.g., “Let’s find out how you don’t get things done.”). Sometimes a review of homework experiences may constitute the primary or sole agenda item for an entire session, which is totally appropriate because the homework is meant to be tied into skills relevant to the other 167 hours of the patient’s life outside the consulting room. The therapeutic agenda focuses on the main topic areas to be addressed during the session. The purpose of setting the agenda is to ensure that time will be spent productively and to decrease the likelihood that the patient and therapist will get to the end of the session and only then remember an important issue worthy of discussion. The structure of an agenda provides a useful anchor for priority topics to make sure sessions stay on track during each meeting and over the course of treatment. Once the agenda has been agreed upon, sessions focus on tackling each of the agenda topics, keeping in mind the overarching therapy goals for the patient. Change does not occur solely through the retelling and processing of events, though these steps provide useful information. The agenda topics provide examples of problematic situations in order to explore alternative ways to have handled these situations, and to identify potential barriers to the implementation of adaptive plans. This goal is accomplished by inquiring about the internal experience—thoughts and emotions—of the individual, the demands of the situation, the behavioral response to the situation, and the ultimate outcome of this sequence. Socratic inquiry, in which therapists ask questions to help

Downloaded by [New York University] at 12:14 14 August 2016 patients understand the different elements of their existing patterns, helps patients sort through the different factors that interfere with the use of coping plans and, conversely, increases the likelihood they will follow through with them. CBT therapists ask for explicit examples of difficult situations and, more specifically, those highlighting functional problems associated with ADHD. This approach makes treatment objectives real and salient on an experiential level and helps to guide the selection of behavioral targets for change. The review of specific contexts provides important data about patients’ internal experiences, which may have connections with past developmental events and beliefs and which, in turn, may affect outcomes. Thus, in addition to providing therapeutic material with which to guide interventions and homework tasks, exploration of real-life examples aids the case conceptualization. 68 Models of Treatment It is equally important to review examples of situations handled effectively by patients. Highlighting the appropriate use of coping strategies and the avoidance of self-defeating patterns (e.g., “Tell me how you were able to get started on that project without falling into the old procrastination pattern.”) helps to bolster adaptive coping skills, that is, providing mental scaffolding for effective coping. These experiences also lay the ground- work for developing revised, adaptive beliefs. This is not to suggest that each agenda item raised in CBT can be neatly and effectively handled in each session. Much of CBT (and psychotherapy in general) deals with patients’ discomfort about the uncertainty of the future, such as making important decisions about jobs or working toward long-range goals. These may require several sessions to be adequately addressed. However, by developing an awareness of their patterns and attribution styles, ADHD patients are better able to consider their options and to make “informed” choices rather than impulsive decisions based on these options. In executive function terms, the session agenda and the review of specific and personally relevant situations (as well as the use of anticipatory problem solving for upcoming situations) serves as a form of “prolongation.” That is, this “pause” (i.e., behavioral inhibition) in the flow of experience allows for adequate problem management including an examination of the difficulties encountered in implementing selected coping strategies. We view the use of implementation strategies and other forms of motivational enhancement as a central component of CBT for ADHD, to be discussed in a later section. For now, a primary goal of the agenda setting for each session is to identify relevant situations faced by the patient in order to discuss the use of coping strategies in context; that is at the point of performance. Even though patient may be facing big problems, we have found it is useful to help them “start small” in order to make facing these problems more manageable.

“Starting Small” Whether defining the treatment goals at the beginning of a course of CBT or setting agenda items at the start of a session, we prefer to err on the side of “starting small” and focusing on problems that are currently relevant and manageable rather than tackling the “big issues” right away. Our rationale for this approach is that individuals with ADHD often have problems prioritizing and facing tasks in their daily lives. Starting CBT by confronting big issues requiring ongoing time and effort may result in too much distress on the part of the patient, thereby running the risk of premature termination in

Downloaded by [New York University] at 12:14 14 August 2016 a clinical population prone to low frustration tolerance. Although it is important to acknowledge the presence of large issues and to discuss how they will eventually be addressed in CBT, it is useful to focus early sessions on smaller, “bite-sized” problems faced by patients that reflect the daily struggles of living with ADHD. In fact, the point can be made that the “big issues” presented by a patient will be addressed through the implementation of “small” coping skills, akin to the skill of breaking down a large task into its component steps. For example, Frank is a 26-year-old young adult who lives with his parents and has worked a series of part-time jobs, enough so that his parents recognize that he has a decent work ethic. He does not have enough consistent income or savings to allow him to move out on his own. He has plans to go back to finish college to improve his Models of Treatment 69 prospects, but he does not enroll because he has “lost enough time.” Frank says that he would like to have a girlfriend but is embarrassed by his living situation, etc. He also states that he has many paths he can follow to improve his situation but that each requires organization and effort that he does not implement. He feels stuck and impatient to move ahead, but his regular routine often involves working and spending an inordinate time at home playing video games or going on the computer. Frank’s therapist empathized with the “stuck” feeling and commented that it seemed overwhelming to hear about all the different options he was facing. They clarified that it sounded as though Frank’s overarching objective was “independence” in terms of moving out, financial independence, being able to have a relationship, etc. After discussing the many possibilities open to Frank, they contemplated some initial steps that were most under his control and that he could undertake before their next meeting. Frank noted that he was easily frustrated by a job search and by thinking about returning to school, although he recognized these were important goals. He further observed that he often wasted money on fast food and other unnecessary purchases so as to improve his mood in the short term (i.e., “retail therapy”). The therapist observed that financial independence was one of Frank’s goals and wondered aloud about setting up a savings account to have a place to deposit at least some of his pay from his part-time jobs. Frank said that he had thought about taking that step on many occasions but had never followed through on it, instead thinking about getting a job that would pay him enough to move out on his own right now. This was likely an unrealistic cognition, and it kept him mired in his current predicament. Defining the steps involved in reserving time to go to a bank and set up a savings account became the behavioral objective for the session, and for the subsequent homework task to perform in between meetings. The tasks were broken down into a “recipe” of step-by- step procedures, various barriers were anticipated, and implementation responses were developed (e.g., “If I have the thought that $50 is too little to start with, then I will remind myself that there have been many times that having $50 would have really helped me.”). Frank started to consider other behaviors he could change to save money, such as taking his lunch to work, putting a certain amount of money from his pay into savings right away, etc. There were many other important issues to address in CBT related to Frank’s work and school goals but this “small” behavioral intervention was a concrete step he took toward independence that helped him to identify and address many of the cognitive and behavioral issues relevant for handling his “bigger” issues. Once a shared understanding of the direction of CBT and a specific problem list is

Downloaded by [New York University] at 12:14 14 August 2016 established, attention turns to using specific cognitive and behavioral interventions to help individuals handle each of their problem areas. As stated earlier, the goal for these interventions is to help patients adopt an expanded view of their options and choices for handling their lives. In the first edition of this book, we divided the discussion of interventions into cognitive and behavioral interventions, focusing within each of these domains on strategies for addressing the functional difficulties encountered by adults with ADHD. In order to provide more elaboration on specific intervention strategies, we have expanded the categories of intervention to include implementation strategies and acceptance-mindfulness along with traditional cognitive and behavioral approaches. Fol- lowing a discussion of those overarching categories, we will review the different coping skills modules that are common elements of CBT for adult ADHD for which we employ 70 Models of Treatment a mix of cognitive, behavioral, implementation, and acceptance interventions designed to help patients be able to develop and execute these coping strategies in daily life.

Categories of Interventions

Cognitive Interventions The hallmark of the cognitive component of CBT is the notion that how people interpret experience, including anticipating upcoming events and reflecting on past events, greatly influences further meaning-making, emotions, and behavioral choices. This model does not propose that “thoughts cause everything,” but rather that cognitions, including images and core belief systems, fundamentally shape experience. Conse- quently, being aware of the meaning ascribed to a situation is a useful and convenient entry point into the tangle of factors that influence experience so as to make sense of a situation and to determine how to handle it, that is, “What am I thinking right now?” Although ADHD is not the result of negative thinking, there is preliminary evidence that ADHD in adulthood is associated with maladaptive thought patterns not fully explained by the presence of mood and anxiety disorders (Knouse et al., 2013; Mitchell et al., 2013; Strohmeier et al., 2013). Cognitive interventions provide a framework with which to introduce a pause in any given situation, take stock of what is happening, and reflect on one’s responses. As in many psychosocial interventions for ADHD, this coping step operates as a surrogate for executive functioning, for example behavioral inhibition and prolongation—interrupting ongoing action and experience in order to assess the situation and make an informed decision of how to handle it. The step of asking, “What is going through my mind right now?” and assessing the moment and the context is a useful first step in making a change. It provides space in which other executive functions can be recruited and additional coping skills deployed, as is discussed below.

Changing Automatic Thoughts Cognitions play a role in emotional management, which is a core feature of motivation, that is, the ability to generate an emotion about a task to promote follow-through (Bar- kley, 1997). Cognitive interventions are used to counter negative anticipations of tasks that in turn decrease motivation (e.g., “This is going to be tedious.”). They also help patients develop attitudes that promote sufficient motivation to get started (e.g., “Once

Downloaded by [New York University] at 12:14 14 August 2016 I get started, it won’t be that bad and I will be glad I worked on it.”). Similar sorts of cognitive modification skills often help mitigate negative emotional reactions to situations and tasks. That being said, adults with ADHD often have amassed a library of negative thoughts and attitudes about themselves and their abilities to manage various aspects of life. In classic CBT, one of the questions commonly asked of patients who make a negative statement is, “What is the evidence on which that thought is based?” with the subsequent discovery that negative conclusions often are based on scant or questionable information. Although often overly pessimistic and overgeneralized in their conclusions, adults with ADHD often cite specific evidence of coping difficulties, mistakes, or poor outcomes in different aspects of life from which the negative view may seem to be a logical and correct Models of Treatment 71 conclusion. The nature of living with ADHD is such that many aspects of life most people take for granted are much more difficult. Endeavors, such as school, work, and relationships, are associated with more negative experiences and accompanying aversive emotions (including boredom). As a consequence, these associations paired with ongoing executive dysfunction and motivational deficits make it harder to engage in various priority tasks and endeavors that are not immediately rewarding or compelling. Task avoidance and procrastination, in turn, lead to further disappointment and setbacks, reinforcing the sense that they “are not fulfilling their potential.” Cognitive interventions focus on identifying and modifying automatic reactions that are “dysfunctional” inasmuch as they may be at least partially distorted or otherwise interfere with their following through on desired coping plans. For example, adults with ADHD commonly procrastinate on tasks via a process of anticipating and exaggerating the difficulties they will encounter, which gives rise to uncomfortable emotions that are used as further justification for deferring a task until later. On the other hand, as was noted earlier, positive thinking can be dysfunctional in certain situations, with patients adopting the view that “it will all work itself out for the best somehow.” Many adults with ADHD exhibit difficulties related to a “positive bias.” That is, they underestimate risks or pin their hopes on ineffective coping plans (e.g., “I work best at the last minute.”). The therapeutic goal is not to achieve positive thinking but adaptive thinking. The cognitive modification strategies aim to help individuals keep options open for managing various tasks and situations, to make informed decisions regarding plans and actions, and to be an active agent in one’s life by following through on these plans and actions. The simple act of recognizing one’s automatic thoughts and viewing them as “choice points” is an important strategy. This habit provides a useful “check in” that can be used to foster behavioral inhibition. Developing a habitual mantra (e.g., Solanto, 2011) for identifying one’s thoughts helps to increase the automaticity of this behavior (e.g. “What am I thinking? Is there another way to look at this situation?”). Another level of intervention involves questioning the accuracy and/or utility of the automatic thought. Reviewing the evidence for a thought may help identify potential distortions in the conclusions that have been made. A useful metaphor for guiding the review and modification of automatic thoughts is that of the Defense Attorney (e.g., Freeman & Reinecke, 1993). That is, negative thoughts are often viewed as being accurate by an individual not because the evidence is valid, but because only the evidence supporting the negative interpretation has been considered. It is

Downloaded by [New York University] at 12:14 14 August 2016 as though the individual was on trial in a Court of Law, the Prosecuting Attorney proffered “negative” evidence, and a sentence is rendered on the basis of this argument. Although a guilty verdict was rendered, it was based on only one view of the evidence without the Defense Attorney having a chance to “object” or to mount a case in the defense of the individual. The coping strategy of considering the situation and cognitive reaction through the eyes of a Defense Attorney whose job is to support the patient’s case to the fullest extent that evidence will allow, helps strike a balance when reaching the final “verdict.” For example, Michael, a college student with ADHD, recognized that, as a consequence of a combination of various strategic decisions (e.g., changed major, dropped courses, etc.), he would need extra time to complete his degree and would not be graduated “on time.” During the several sessions after this realization, Michael encountered 72 Models of Treatment greater difficulties using the coping strategies he had previously used for keeping up with his school work. When exploring the triggers for these difficulties, Michael said that he was embarrassed by the fact he would need extra time to be graduated and, even though he was on track to earn a degree, he viewed his college performance as tainted and himself as a “substandard student.” He also wondered aloud if he should find a job rather than continue to “waste money” in school. Michael’s initial interpretation of the situation is accurate: He will require at least one more semester than his close friends to complete his degree requirements. However, the meanings ascribed to this fact, the case made by the Prosecuting Attorney, are self-defeating inasmuch as they interfere with his goal of completing college. There is a list of widely cited cognitive distortions drawn from initial work with depressed patients that are also relevant for other conditions, including adult ADHD. Declarations made by patients such as, “I can’t do that,” “I just know that plan will not work for me,” or “I’m a total failure” offer opportunities to explore how individuals came to those conclusions and to ferret out possible core beliefs and candidate schema. In Michael’s case, the Defense Attorney noted that he engaged in “selective abstraction” and “labeling,” focusing on the aspects of the situation that support his negative view. In doing so, he ignored alternative evidence (e.g., “I am still on track to finish college. I am fulfilling the school’s graduation requirements.”) and negatively categorizing himself as a consequence (e.g., “substandard student”). These conclusions were initially spurred by a common distortion seen in adults with ADHD, comparative thinking, or judging oneself based on comparisons with others (“I’m not a good student because I will not graduate at the same time as my friends.”). Michael and his therapist identified these factors and spent time thinking them through and considering alternatives. He was surprised to learn that recent US Depart- ment of Education statistics use 5 years as the marker for graduating “on time” (Snyder, Dillow, & Hoffman, 2007). Moreover, nowadays the vast majority of college students are considered “nontraditional,” inasmuch as they do not complete college in 4 consecutive years immediately following high school. By using the Defense Attorney metaphor to reconsider his situation, Michael acknowledged that he would have been at risk to drop out of college had he not changed his major and withdrawn from courses along the way. Moreover, even though he was taking extra time, he still had to complete the same requirements for graduation, therefore “(his) degree will not have an asterisk on it.” A useful tool for working through distorted thoughts is the Dysfunctional Thought Record (DTR; Beck et al., 1979). It is a simple form that helps individuals to record prob-

Downloaded by [New York University] at 12:14 14 August 2016 lematic situations and to draw connections between their thoughts, feelings, and outcomes. Variations on this template may be used to personalize the interventions for an individual. A simple two-column version can be used to identify the automatic thought in one column and to develop an alternative thought in the second column (or the metaphors of the Prosecutor and Defense Attorney may be used). Additional columns can be added to include the triggering event, emotional reactions, specific type of distortion, behavioral action plan for managing the situation, and/or a final column for the ultimate outcome of the situation. Examples can be reviewed in session to illustrate how the form is used and to start considering alternative interpretations of those problematic situations. It is not surprising that the automatic thoughts of adults with ADHD tend to cluster around anticipations of one’s relationship with tasks (e.g., “This is going to be hard. I’m Models of Treatment 73 not good at writing.”) and self-recriminations related to difficulties managing these tasks (e.g., “I forgot to pay my credit card bill again. I’m such a loser.”). Left unchallenged, these negative thoughts can trigger a cascade of further self-criticism, emotional distress, and avoidant behavior. There are useful questions that help guide cognitive modification efforts, such as “If a friend of yours was in the same situation and had this thought, what would you tell him/her?” “What’s the best that could happen? What’s the worst that could happen? Could you handle it? What’s the most likely outcome?” “Will this situation seems as important 24 hours from now? Next week? Next year?” The therapist and patient work together to develop an alternative interpretation of the situation (e.g., “How would you advise a friend who was in the same situation?”) that maintains the patient’s self-esteem and opens up possibilities for emotional self- regulation and problem management (e.g., “I’m frustrated with myself that I forgot to pay the bill, but I’m not the only person who’s ever done that. I’m going to try writing the next due date in my planner as a reminder.”) (see Table 2.3). The very act of monitoring the connection between triggering events and one’s reactions, not to mention writing them down, represents a challenge to people with ADHD. Whether using paper thought records, electronic versions, apps that facilitate self- monitoring, or other means, follow-through is difficult for many adults with ADHD. Nevertheless, the ability to externalize information is an essential coping skill that is learned and practiced in CBT. Creative solutions may be developed in collaboration with patients to make the cognitive modification skills portable and easy to use, the goal being that the individual develops the means for interrupting and changing unfulfilling patterns. In addition to using different technologies for recording (including recycling pieces of scrap paper or envelopes), an underutilized skill is simply talking out loud to oneself, verbalizing the negative thought, and then verbalizing an adaptive thought. This approach requires more complete recognition of the automatic thought in terms of expressing it in a complete sentence and then formulating a response. Hearing one’s inner voice while the automatic thought is scrutinized and reworked helps to externalize the process and to render the thought more apparent and compelling. Of course, this verbalization of thoughts and problem solving can be performed in the context of a trusted relationship, such as “talking through” a situation with a significant other or a therapist. A silent, internal dialogue of identifying the negative view and developing an adaptive view can be used, too. The main point is to take a few moments to go through the process and note its effects on the individual’s thoughts and emotions.

Downloaded by [New York University] at 12:14 14 August 2016 The ultimate goal of cognitive modification is not limited to a specific thought record form—a simple line drawn down the middle of a sheet of paper dividing it into columns for the automatic thought and the corresponding adaptive response is sufficient for many people. Rather the recognition that there are options in how to respond to and/or make sense of situations is what matters most. Thus, if a patient does not produce a completed thought record form but is able to identify his or her automatic thoughts in different situations and to develop alternative thoughts, it is evidence that the patient understands and is able to use this strategy. On the other hand, if a patient seems unable to recognize the effects of her or his thought processes, the therapist and patient should take time to complete a thought record during session to practice this skill. Table 2.3 Common Cognitive Distortions Observed in Adults with ADHD

• Magnification and minimization = Exaggerating the negative aspects of a situation and underestimating the positive aspects (e.g., “Working on this paper is going to be tedious and unproductive, and it will ultimately be a waste of my time.”). • Comparative thinking = Judging yourself based on how you or your actions measure up against those of others—even though this comparison is often unfair or inaccurate (e.g., “I spend hours preparing for a brief presentation at work and my colleague does not look stressed and is able to do a good job without much preparation.”). • All-or-nothing thinking = Also known as black-or-white thinking, this error refers to viewing yourself or your performance in absolute, categorical terms (success or failure) that does not acknowledge a continuum of qualities or performance (e.g., “I still procrastinated on working on my taxes and I missed my haircut appointment. This treatment for adult ADHD is not working at all and I’m still at square one.”). • Awfulizing = Also referred to as catastrophic thinking, this error refers to inflating the negative aspects of a situation to make it seem worse than it really is (e.g., “My boss pointed out that I’ve arrived late for work and said that he needs me here on time. He’s getting ready to fire me.”). • Mind reading = Assuming that you “just know” what others think about you or a situation without clear evidence (e.g., “It is no use asking for an extension at this point. I just know the professor will say no.”). • Anticipating the future = Also known as fortune-telling, this thinking error refers to assuming things will inevitably end up going badly (e.g., “I know that I will make positive changes for a little while, but I’ll eventually mess up and then I’ll be right back where I started.”). • Emotional reasoning = Using your emotional reaction to a situation as evidence for your negative conclusion (e.g., “I feel like an idiot.”). This error also appears in the thought that “I must be in the mood to do a task, or else I cannot do it.” • Overgeneralization = Taking a circumscribed example of a mistake and blowing it and its implications out of proportion (e.g., “I did poorly on a test. I do not belong in college.”). • Fallacy of fairness = The unrealistic expectation that things in life will work out in a fair and equitable fashion (e.g., “It is not fair that I have to spend more time than my classmate to complete the same reading assignment.”). • Should statements = Holding yourself or others to overly rigid rules that create unrealistic performance expectations that result in disappointment (e.g., “I should be able to sit down and read for an hour without having to take breaks.”). • Jumping to conclusions = Making rash, extreme assumptions about yourself, someone else, or a situation without having all the evidence (e.g., “I want to organize my closet but there is too much in there. There is no way I can do this.”). • Labeling = Using judgmental or negative terms to describe yourself, others, or a situation that are unfair characterizations and do not focus on specific behavioral issues (e.g., “I procrastinated because I’m lazy” versus “I procrastinated because the task seemed Downloaded by [New York University] at 12:14 14 August 2016 overwhelming and I escaped to the computer.”). • Magical thinking/Positive bias = Overreliance on circumstances out of your control, “good luck,” or the unrealistic expectation that there will be a simple solution and underestimating actions you can take to deal with issues (e.g., “I work best at the last minute—it will work out, somehow.”). • Externalizing blame = Inordinate responsibility and culpability is placed on others (e.g., “My doctor should give me a full session, even if I show up late. That is why I’m here.”). • Selective abstraction = Also known as filtering, you focus on information that supports a negative view, and dismiss other information (e.g., “I got a late start, hit traffic, and missed my flight. I got the next flight and arrived a few hours later than I expected. The meeting went well and preparing in advance paid off, but the fact I missed that flight wrecked the whole trip for me.”).

Note : Drawn from Beck (1976), Burns (1989), Rostain and Ramsay (2006a). Models of Treatment 75 Although it overlaps with the behavioral domain, testing out one’s thoughts and assumptions in the form of personal experiments is another useful technique. These experiments provide opportunities for practicing the requisite skills for managing ADHD, about which patients often have doubts. The visceral, felt experience of being able to face a situation that was previously avoided, discovering that a new coping strategy produces a desired outcome, or even the positive experience of completing a task, however mundane, can be powerful learning events that serve to modify outlooks and behaviors. For example, Michael, the college student who was bothered by the fact he would not be graduated on time eventually shared his frustration with his friends. At the outset, he learned that rather than viewing him negatively, his friends regarded him as a very good student and actually respected the decision he made. One of his friends, unbeknownst to Michael, had taken summer session courses every year in order to keep on track with graduation requirements. Michael also started to encounter many more students in his situation and recognized that he did not view these peers as “substandard.” In addition to modifying his outlook, Michael recognized that he had been reluctant to reach out to his instructors for help in previous semesters, thinking that by doing so he would be viewed as a poor student. He agreed to an experiment of attending instructors’ office hours for each of his remaining classes at least once in order to have the experience of making contact with each of his teachers. The development and implementation of new coping skills is central to CBT for adult ADHD. Adults with ADHD, many of whom have gone undiagnosed most of their lives, very often have unsuccessfully tried to adopt coping strategies used by individuals without ADHD and have not developed a set of coping skills tailored to an understanding of their ADHD profile. In some cases, patients may have been frustrated in their attempts to apply suggestions offered by books or websites devoted to ADHD. Consequently, many facets of daily life such as time management, organization, and managing distractions have become associated with pessimistic thoughts: “I can’t do that. It doesn’t work for me.” When asked for the evidence to support the pessimistic thought mentioned above, individuals often say that they have repeatedly tried to implement specific coping skills without success. What we find, however, is that they often have been unaware of the effects of their ADHD and have repeatedly tried to use coping skills that work for other people but that have not been personalized to account for ADHD. Moreover, the first sign of difficulty is used as evidence the skill does not work. We use CBT as a laboratory for researching different coping strategies to find what

Downloaded by [New York University] at 12:14 14 August 2016 works for the individual. Individuals with ADHD are often quick to become frustrated and to abandon a project when it appears to not be working out well. Reframing these difficulties as normal and as an essential component of trial-and-error learning helps foster a sense of resilience. Sticking with a plan to gain an adequate assessment of its usefulness before deciding to abandon it and try something else is a major shift in thinking.

Changing Core Beliefs and Schemas For many individuals with relatively uncomplicated cases, the conceptualization and treatment are straightforward. There are many difficulties associated with executive dysfunction that may trigger circumscribed negative self-evaluations, but the individual’s 76 Models of Treatment self-esteem is generally intact. Moreover, the individual likely has “islands of competence” (Brooks, 2001) that provide buffers for one’s sense of self. There may be some instances of self-criticism or frustration in the course of implementing coping skills, but the person will likely stay engaged in treatment and achieve good outcomes. Individuals with adult ADHD seen in standard clinical practice will likely have more complex presentations and more severe impairments and comorbidities than are represented in the results of most clinical outcome studies. The executive functions affect functioning in domains of life from which we derive our sense of self. Sigmund Freud described the two elements of a fulfilled life as “to love and to work” (Erikson, 1963). Relatedly, two common schemas seen in patients with ADHD are unlovability and incompetence. The thread binding these views of human nature is that we derive a sense of self from the ability to get things done and to maintain healthy relationships. ADHD is known to have negative effects on these domains of life and, therefore, exerts a corro- sive effect on one’s sense of self or core belief system. Schema and core beliefs develop as part of the lifelong process of making sense of experience. A particularly fertile time for their formation is during childhood and adolescent development. Because emotional experiences have a head start on cognitive development, early schemas are strongly associated with affect. These experiences and resulting schema can be positive and adaptive, such as learning that family can disagree and argue but still be stable and supportive or that someone can make mistakes while learning a new skill but that persistence pays off with improved performance. By contrast, a lifetime history of frustrations associated with ADHD runs the risk of being associated with persistent and pervasive negative self-views. Considering that they are rooted in developmental experiences, revision of maladaptive beliefs usually requires both (1) an experiential component of assimilating novel experiences that are incongruent with existing negative beliefs and (2) a cognitive component of accommodating the belief system to account for these new experiences. The person with a failure schema, for example, who assumes axiomatically that he will spoil any important undertaking, will be asked to face some tasks he would typically avoid. He will be asked to tolerate some uncomfortable emotions in the process in order to get and stay engaged and eventually have new and better experiences. This is the experiential component. He will also be asked to reassess his belief when he finds himself making progress on his goal of completing work projects on time (e.g., “How do you make sense of the improvements you have made in light of the fact you have met every deadline over the past quarter at work?”). Furthermore, negative belief

Downloaded by [New York University] at 12:14 14 August 2016 systems can be challenged by encouraging patients to identify, emphasize, and utilize their personal strengths and abilities, thereby fostering strengths-based beliefs as a counterpoint to the existing negative beliefs. This leads to a more adaptive ratio of different capabilities (e.g., “You describe yourself as ‘incompetent’ because you mis- judged how long the project would take. However, you’ve also described yourself as someone who does ‘whatever it takes’ when facing challenges. If you break down what you need to do for the project into strict behavioral steps, what will it take to complete the project?”). These deeper-level schemas and beliefs are not as easily accessed and modified as are automatic thoughts. An effective strategy for drawing them out is the downward arrow technique (Burns, 1980). In this exercise, a patient is encouraged to consider the Models of Treatment 77 connection of an automatic thought to more deeply held, underlying beliefs. When an automatic thought has been identified, the patient is then asked, “Assuming for a moment that your thought is true, what would be the meaning of it for you?” Subse- quent thoughts are progressively met with the same question until the relevant underlying belief is revealed. For example, John, a 41-year-old graphic artist had not filed his federal income taxes in 3 years. He hired an accountant to help him and was asked to submit personal financial information in order to complete his tardy tax returns. However, John continued to procrastinate on sending the forms. This issue was placed on the agenda for one of his early sessions of CBT:

Therapist (T): So, let’s address the issue of procrastination regarding your fi nancial paperwork. What is the issue you are facing? John (J): My accountant needs my receipts, W-2 forms and other paperwork from the past 3 years, and I still haven’t started to get it together for him. T: What would be the fi rst step? J: I have to fi nd a lot of these papers, though I generally try to shove most tax papers into the same drawer in a fi ling cabinet. I guess I could open that drawer and sort through the papers in there. T: What is your automatic thought about taking that fi rst step? J: There will be a mound of confusing papers. I will be overwhelmed. T: For the moment, let’s assume that this is the case, that you are overwhelmed when you open the drawer. What would that mean to you? J: That I really messed up this situation and I should be more responsible about these sorts of things. T: And what is the implication of these thoughts? J: I’ll probably have to pay some sort of tax penalty for my irresponsibility and now my family will have to suffer fi nancially for my mistakes. T: Again, without yet questioning the accuracy of this thought, what does that thought mean to you? J: That I’m not doing a good job taking care of things that affect my wife and children. And that I’m not smart enough to just give this stuff right away to an accountant who can take care of it for me before the tax deadline. T: What does that conclusion mean to you? J: I’m not a good husband or a good father. I’m incompetent when it comes to

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As we can see, though procrastination is a common problem for ADHD adults, John’s avoidant behaviors and incompetency beliefs reciprocally compound each other, resulting in his continued delay in dealing with his taxes and his negative view of himself as a poor provider for his family. Thus, behavioral experiments devoted to reducing procrastination and handling problems in a timely manner represent not only coping skills for ADHD, but also experiential exercises with which to help John challenge his negative beliefs. Additional cognitive interventions can help John to identify positive ways he fulfills his roles as father and husband that have nothing to do with whether or not he procrastinates. 78 Models of Treatment For many adults with ADHD, it only takes two or three questions before reaching the underlying negative belief. As we mentioned earlier, individuals with mild, uncomplicated cases of ADHD may not exhibit maladaptive schema and CBT for these individuals helps them to learn to cope better in their current environments, such as improving their organizational skills at work. In other cases, the various cognitive and behavioral interventions hopefully provide ways to modify the belief system. Managing the effects of ADHD and consistently implementing effective coping strategies remains central to CBT for adult ADHD. However, clinicians must pay attention to how the underlying belief systems, that is, maladaptive schema, interfere with adult ADHD patients’ engagement in the change process, and provoke intense reactions to difficulties encountered in this process. The targets of cognitive interventions are the various thoughts and rationalizations that interfere with coping with the effects of ADHD and executive dysfunction. Cogni- tive interventions have played a heretofore underappreciated role in emotional regulation and self-motivation in efforts to manage ADHD. The ultimate goal of the cognitive interventions is to foster resilient outlooks that support the persistent use of coping strategies for ADHD even in the face of ongoing symptoms and challenges. Despite its emphasis on exposure to various situations and testing out one’s assumptions, CBT is not often considered an experiential form of psychotherapy. However, CBT for adult ADHD emphasizes the application of various strategies with which to manage the effects of ADHD on one’s life. Therefore, the behavioral interventions discussed in the next section are paramount. It is the consistent use of coping strategies to improve functioning that is the ultimate measure of the effectiveness of treatment.

Behavioral Interventions The aim of behavioral interventions is to help patients form new behavior patterns, gain new coping skills, and improve outcomes in domains of their lives that heretofore have proven difficult to manage. The dual purpose is to improve functioning and, consequently, to gain novel experiences from which to revise one’s attitudes and outlooks so as to sustain adaptive functioning. There are several skill domains that are standard fare for most psychosocial treatment programs for adults with ADHD, such as time management, organization, and other manifestations of the executive functions. There are many easily accessible resources providing useful information about specific coping skills and ways to manage adult

Downloaded by [New York University] at 12:14 14 August 2016 ADHD. However, adults with ADHD describe knowing what they need to do but having difficulty actually doing so, which is the biggest challenge to employing behavioral interventions. One of the important behavioral principles in CBT for adult ADHD is ensuring that a targeted behavior is being sufficiently reinforced to increase its frequency. This is a basic behavioral principle but it is important to emphasize for adults with ADHD because they often experience delay aversion and reward deficiencies, making reinforcement difficult (Sonuga-Barke, 2011). Typically this involves applying positive reinforcement to a particular coping strategy, such as watching a football game as a reward for completing yard work. The use of linking stimuli can be used to help someone engage in a challenging task, such as listening to enjoyable music while doing housework. Models of Treatment 79 Similarly, it is very helpful to develop adaptive behavioral routines to improve initiation and follow through on tasks, and to decrease any potential interference from emotional frustration associated with disorganization. In working with adults with ADHD, we discuss the behavioral scripts they have developed that either enable or hinder follow-through on desired plans. By identifying the existing scripts that interfere with their intentions, alternative behavioral scripts can be developed. For example, Tom said that he often left work in the afternoon with plans for exercising and for researching potential certification programs that would help him get promoted at work. At the end of his shift, his plans for when he got home seemed reasonable and he felt motivated. However, by the time he reached his apartment, his motivation had waned and he invariably got distracted by a variety of low priority tasks that allowed him to “unwind” but that were unfulfilling and ultimately undermined his best-laid plans. More specifically, Tom and his therapist laid out his existing “arriving home” behavioral script. They figured out that arriving home after work was associated with feeling tired and the attitude of “Now I can relax.” The initial behavior of sitting on the couch and turning on the television was associated with being sedentary, accentuating the fact he was somewhat tired after a full day at work, and reinforcing that it was pleasant to “unwind and ‘veg out’” for a while. Tom also had difficulties disengaging from the television, where he was always able to find programs or video games that were immediately more compelling than any of the plans he made on his way home. After a while of playing out this script, he determined that he was “not in the mood” to exercise or to search for a job. He comforted himself with the thought that he would perform these tasks tomorrow. Those rationalizations were not a plan but were rather part of the unproductive behavioral script. It was pointed out to Tom that there was nothing unethical, immoral, or illegal about how he spent his time after work. However, Tom agreed that this habitual routine, though relaxing, was not fulfilling and interfered with his longer-range plans: the hallmark of executive dysfunction. Tom and his CBT therapist identified the behaviors he would like to reinforce in a competing “exercise” script. It was helpful to introduce the coping skill of entering a room with a plan. This phrase is used to reinforce how it is easy to fall into behavioral patterns that are prone to disruption by various sources of interference or temptations unless there is a competing option. Thus, in Tom’s case, he focused on “entering his apartment with a plan,” a behavioral plan that he could execute instead of his overlearned habit of sitting on

Downloaded by [New York University] at 12:14 14 August 2016 the couch and watching television. Changing the behavioral script involves defining “tipping points” at which different behaviors can be implemented. Tom noted that he used to enjoy running and that it would be a good activity for him when he arrived home from work. He and his therapist defined the specific steps he would follow when he arrived home from work that would promote the likelihood he would go for a run, that is, “enter the room with a plan.” Tom said that the plan of going for a run sometimes seemed overwhelming—he could not reconcile feeling somewhat tired after work with the image of exerting himself. Tom and his therapist developed a step-by-step plan or “recipe” he could follow when he arrived home (e.g., “I will set down my things from work, I will go to my bedroom and put on my running clothes, I will get my iPod, and I will walk out the front door and start running.”). Tom identified 80 Models of Treatment the rationalizations that might interfere with his plan (e.g., “I’m too tired. I’ll relax first and run later.”) and developed adaptive responses (e.g., “I know I won’t run later. I always feel better and more energized after a run. Once I get started, it will be easier.”). Tom’s plans for handling difficulties that could interfere with the implementation of his plan also were reviewed (e.g., “How will you handle it if your iPod is not charged?”). The new behavioral script helped Tom to increase the number of times in a week he went running, providing him an opportunity to develop a reasonable routine. Using this template for changing entrenched behaviors, similar approaches were used to help Tom engage in other tasks he had been putting off, such as researching certification programs relevant to his job and taking care of simple errands, such as food shopping after work. In addition to the positive reinforcement of behavior (i.e., the introduction of a positive stimuli to increase the frequency of a behavior), it is important to help adults with ADHD recognize the role of negative reinforcement (i.e., the removal of an aversive stimuli to increase the frequency of a behavior) in maintaining behavior. Negative reinforcement is particularly relevant for targeting escape behaviors that undergird procrastination and avoidance. For completeness, it should be pointed out that negative reinforcement is different from punishment. Punishment is the introduction of a consequence that reduces the frequency of a behavior. A positive punishment is characterized by the introduction of an aversive consequence, such as a speeding ticket or criticism from a boss for being late. Negative punishment is characterized by the removal or loss of a desired stimulus or opportunity, such as losing an opportunity to take a class by missing the enrollment deadline or having to miss watching a football game on the weekend to catch up on overdue work. Intact executive functions help individuals to organize and follow through on behaviors that have long-range benefits but that might not be immediately reinforcing (e.g., working on a paper due next week), or at least not as compelling as other available options (e.g., watching a football game on television). Adults with robust executive functions are able to generate motivation associated with the future benefits of following through on priority tasks in the here-and-now, perhaps demonstrating “grit” (Duckworth, Petersen, Matthews, & Kelly, 2007), which is a penchant for goals that require sustained effort to achieve. Adults with ADHD, on the other hand, experience motivational deficits that make it harder to generate this sort of motivation for long-range outcomes. They are also prone to succumb to immediately pleasurable activities, or the positive visceral feeling

Downloaded by [New York University] at 12:14 14 August 2016 of relief that is experienced at the moment a choice is made to avoid working on the paper (i.e., escape from emotional discomfort) and instead to watch the football game, a textbook example of the negative reinforcement (i.e., removal of stress) of escape behavior. This pattern makes it more likely that the person will engage in avoidance/ escape in the future. Most behavioral interventions focus on helping adults with ADHD to engage in tasks that are typically avoided, at least until facing a deadline. More specifically, these interventions require a degree of tolerance of discomfort (i.e., frustration tolerance) in order to engage in a task. The primary objective is for the patient to experience positive reinforcement for task engagement/completion instead of negative reinforcement from escape behavior (i.e., avoidance). Models of Treatment 81 In instances like procrastination, an adult with ADHD has the skills and capacity to complete a task, but struggles with negative anticipatory thoughts and feelings leading to a performance deficit. In cases where there are skill deficits, and where the goal is to learn and practice new coping behaviors, there may be issues related to low confidence related to trying new things, or worries about making mistakes that others might notice. In either case, behavioral interventions provide progressive exposure experiences that enable adults with ADHD to follow through on personally relevant objectives so as to gain new experiences in managing uncomfortable emotions, to learn new coping skills, and to change their outlooks and attitudes. Behavior change is difficult, particularly for adults with ADHD who must grapple with the fact that they have greater difficulties with the delay of gratification that makes them prone to give into distractions and other compelling temptations. What follows are additional interventions we have employed in the treatment of adult ADHD that function synergistically and augment the cognitive and behavioral interventions described above.

Implementation Strategies ADHD is a performance problem more than it is an information problem. Most adults with ADHD will report “I know what I need to do, but I cannot get myself to do it” or “I could coach someone else in how to handle a situation, but I cannot take my own advice.” Therefore, it is essential to augment the aforementioned elements of CBT for adult ADHD with strategies designed to increase the performance of the various coping skills for managing ADHD and executive dysfunction. We have found the research on specific implementation intention strategies (Gollwit- zer & Oettingen, 2011), as well as other interventions focused on motivational enhancement and follow-through on coping strategies to be useful extensions of CBT for adult ADHD. This research has focused on improving follow-through on health care recommendations and other aspects of treatments that require the active participation of, and performance by, patients to gain optimal outcomes. More specifically, implementation intention strategies have been modified for use with children with ADHD (Gawrilow & Gollwitzer, 2008; Gawrilow, Gollwitzer, & Oettingen, 2011a, 2011b), and there are obvious applications for adults. The motivational deficits associated with ADHD also require consideration of ways to enhance follow-through. (We will use the term “implementation strategies” as an umbrella term for specific implementation intention strategies and

Downloaded by [New York University] at 12:14 14 August 2016 other interventions that promote implementation.) Implementation strategies can be considered a form of cognitive rehearsal for how to handle certain situations that occur in specific contexts: “Self-regulation by implementation intentions entails delegating action control to pre-specified critical environmental cues” (Gawrilow & Gollwitzer, 2008, p. 263), thereby externalizing tactics to promote the use of executive function coping skills. That is, in addition to identifying opportunities for using coping skills and thinking through risk factors associated with a situation, specific behavioral tactics are outlined that define how coping plans will be employed as well as maintained in the face of potential distractions. Considering the role of emotions in motivation, coping plans will involve handling the affective associations with various plans in context. Implementation intention theory posits that these rehearsed, prespecified 82 Models of Treatment environmental cues operate by externalizing the executive functions, becoming activated if and when those situations are encountered. Thus, the implementation intention “If I take the incoming mail to my kitchen table, then I will sort through it and only keep bills and other items requiring action” should increase the likelihood of completing this task once a person retrieves that day’s mail. Similarly, the behavioral scripts previously discussed in the section on behavioral modification lend themselves to an implementation focus. In addition to initial task engagement, we have found implementation strategies useful for helping patients persist on task, stop and transition to new tasks, and avoid perseveration (i.e., getting stuck), which is consistent with their self-regulatory functions (Gollwitzer & Oettingen, 2011). These strategies provide patients with mindsets and tactics with which to handle the typical distractions and frustrations they encounter when using their coping strategies. Said differently, specific vulnerabilities stemming from ADHD are anticipated insofar as they may arise in a particular setting. “If-then” coping plans are developed to address these vulnerabilities (Gawrilow & Gollwitzer, 2008). Specified pivotal situations or “tipping points” that pose a risk for activating maladaptive patterns are identified, offering an opportunity to employ an adaptive executive function coping skill instead. The “risk” in the context is thus associated with an “if-then” coping scenario, so the “risk” now serves as a “cue” to promote an adaptive response. Individuals with intact executive functioning and motivation are generally able to navigate these processes in daily life, using executive skills like “error detection,” “interference control,” “problem management,” and subsequent “task persistence.” Adults with ADHD, on the other hand, benefit from explicitly discussing these plans and rehearsing follow-through options to combat executive dysfunction and motivational deficits. For example, Tom, the young man who left work with plans for exercise, later focused on looking into certification programs for his job, but encountered other difficulties following through. In particular, it was difficult for him to initiate research on the availability of such opportunities. He developed a “behavioral script” in which he arranged a realistic expectation for his objective (e.g., “I will look on the Internet and find out when and where the certification programs are offered, their cost, etc.”), a defined location (e.g., “I will go to the local coffee shop that has free Wi-Fi.”), and a realistic task and time frame (e.g., “If I go to the coffee shop at 10 a.m. on Saturday morning, then I will spend at least 30 minutes on my search before I take a break.”). Cognitive interventions were used to address task-interfering thoughts (e.g., “I usually do not like doing work on the weekend, but this is an important project for me and 30 minutes is not a long time. I’ll still have my

Downloaded by [New York University] at 12:14 14 August 2016 whole Saturday ahead of me, and I will feel good about what I accomplished.”). Implementation strategies further enable follow-through by anticipating and developing strategies for handling examples of executive dysfunction that could undermine the performance of this plan. Tom and his therapist anticipated a number of possible scenarios that could disrupt his adaptive behavioral script, e.g., “What if the coffee shop is crowded and there are no seats available?” “What will you do if the Wi-Fi is down or you cannot connect to it?” or “What if you are there and a friend of yours happens to show up?” Plans for managing these scenarios are talked through, which follows the model of using if-then coping plans (e.g., “If it is too crowded, then there is a fast food restaurant across the street where I can go that offers Wi-Fi. If the Wi-Fi at these places is not working, my home Internet provider has hotspots that I can access using my Models of Treatment 83 account.”). All contingencies cannot be anticipated, but this rehearsal creates “cues” for adaptive coping with the common risks inherent in a particular situation. In this vein, we have increasingly found it useful to differentiate between a goal focus and an implementation focus for behavioral objectives. Having these two mindsets with which to approach behavior modification plans also help overcome barriers to change. A goal-focused orientation is a familiar and intuitive approach for achieving desired behavioral outcomes. There is a specific desired outcome or product that an individual hopes to achieve. This superordinate goal helps clarify and guide specific subordinate behavioral steps required to achieve it. For example, an individual might have the goal to keep up with paying bills and other household paperwork (e.g., renewing automobile insurance). This overarching goal helps her to review her incoming mail on a regular basis and to devote time to paying bills as they arrive. Such an outcome-driven goal is prudent and can be helpful for carrying out proactive behaviors. However, such long-term outcome goals are often too distal and too weak for most adults with ADHD. Thus, these goals exert little influence on behavior at the point of performance. For example, an adult with ADHD has the goal to keep up with household bills and paperwork but feels overwhelmed when facing a stack of incoming mail (e.g., “I cannot deal with this right now. I’ll deal with it later.”). Driver’s license renewal or quarterly tax payment paperwork appears confusing at first glance, does not require immediate action, and is likewise set aside, either to be forgotten or only to be faced when the person faces an impending deadline or penalties for lateness. The “goal” of keeping up with paperwork remains intact but there are problems with daily follow-through. In such cases, a reformulation of behavior change from an outcome focus to a proxi- mal, process focus may be useful. More specifically, adopting an implementation-focused orientation will better support improved self-regulation and behavioral follow-through (Gollwitzer & Oettingen, 2011). That is, we focus on defining specific, discrete implementation tactics or steps that help the adult with ADHD engage in a task that increases the likelihood of follow-through on the overarching goal. Although poor task persistence and sensitivity to disruption affects most adults with ADHD, once they are engaged in a task, there is increased opportunity for the experience of positive feedback associated with productivity along with a decreased sense of aversion to the task that facilitates ongoing performance. For example, in the case of the individual with ADHD who has difficulty keeping up with bills and other household paperwork, there will be some component steps that interfere with following through on the goal, such as taking time to sort through the

Downloaded by [New York University] at 12:14 14 August 2016 daily mail. Exclusive attention is paid to the relevant issues (e.g., automatic thoughts, avoidant behaviors) that may interfere with execution of that task and an alternative plan is developed (e.g., “What thoughts go through your mind when you see the pile of the day’s mail? What do you end up doing?”). Thus, rather than focusing on a large goal (e.g., keeping up with bill and paperwork) the patient focused on the steps required to initiate sorting through that day’s mail (e.g., “Let me first go through each piece of mail and discard the unnecessary items. I’ll then open the envelope that seems most important and deal with it”). Potential barriers to follow-through are identified and addressed, thereby these “risks” are turned into “cues” for good coping (e.g., “If I think I can do this task later, then I will remind myself that it will probably take less than a minute and then it will be done,” or “If my dog bothers me to go outside, then I will bring the mail with 84 Models of Treatment me outside and take care of it there.”). Eventually steps toward fulfilling the original “goal” are achieved as a side effect of progressively implementing small, manageable changes for these sorts of pivotal behaviors. Many of the cognitive and behavioral interventions discussed earlier serve double duty as implementation strategies. It is through their specific application as coping tactics cued by environmental factors that they become specific implementation strategies. Moreover, these sorts of modifications and additions to the traditional CBT model characterize the way in which the model continues to be adapted to the unique needs of adults with ADHD. Another important element of CBT for adult ADHD is a focus on emotional regulation, which includes distress tolerance. More specifically, handling a degree of discomfort and frustration is an executive skill that is vital for successful implementation of coping strategies. Emotional discomfort is a trigger for escape behaviors that eradicate (for now) the source of the discomfort thereby insidiously negatively reinforcing avoidance and procrastination. While cognitive, behavioral, and implementation strategies each play a role in emotional management, managing emotions within the context of coping with the effects of ADHD on one’s life necessitates an ability to handle uncomfortable feelings in the service of longer range goals. The next section summarizes approaches for emotional management to promote follow-through and persistence with coping skills.

Acceptance-Mindfulness Interventions Another development within the CBT model of treatment has been the use of acceptance-mindfulness as a coping strategy. In our use of acceptance-mindfulness, we cast a wide net over several different, interrelated intervention approaches for adult ADHD, including mindfulness, toleration of discomfort while following through on tasks, and understanding and normalizing the effects of ADHD while maintaining a resilient, problem management approach (rather than giving up). Arguments could be made that these approaches represent variations of typical CBT interventions, although we have found it helpful to separate them out for the purposes of conceptualization and discussion. The skill of noticing and accepting experience without having it necessarily dictate behavior is not new to CBT. The cognitive component of CBT rests upon the notion that our stream of thoughts represents possible views of a situation, and these are open to

Downloaded by [New York University] at 12:14 14 August 2016 reassessment. Similarly, accepting and managing difficult emotions without giving into their impulses is a hallmark of Dialectical Behavior Therapy for Borderline Personality Disorder (DBT; Linehan, 1993), which has been modified for use with adults with ADHD (Hesslinger, Philipsen, & Richter, 2004). Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) represents a contextual behavioral analytic approach that emphasizes the fact that various degrees of distress and discomfort are the norm rather than the exception in human experience. Uncomfortable emotional experiences are to be expected in the course of life and can be handled through “acceptance” at the same time that individuals sustain their “commitment” to valued personal objectives. Finally, mindfulness-based approaches have also been adopted for managing ADHD (Zylowska, 2012; Zylowska et al., 2008). We acknowledge that we have provided Models of Treatment 85 an all too brief and simplistic overview of these different approaches. The point we want to emphasize is that the notion of “acceptance-mindfulness” has great utility in the treatment of adult ADHD. From a clinical standpoint, we have found the concept of acceptance to be a useful one for helping adults with ADHD to cope better. The first use is simply to help individuals recognize and normalize that they will encounter periodic difficulties related to executive dysfunction. As we have noted before, the accurate diagnosis of ADHD and an understanding of its manifestations are the first cognitive modification interventions in treatment, providing an alternative to the “character flaw” view of coping difficulties. However, even though ADHD has been identified, its effects remain persistent and frustrating. Acceptance of ADHD is not the same as acquiescence—that is, the notion of an accepting attitude toward the common difficulties does not mean the individual with ADHD is resigned to a helpless, hopeless outlook. Rather, the difficulties commonly associated with ADHD are normalized and a coping mindset can be employed, similar to a very tall person being accepting of the need to duck under a doorway (or accepting a periodic bump on the head), or a left-hand dominant individual dealing with the fact that many items in society are geared for right-hand dominant individuals. Perhaps the most useful aspect of the acceptance-mindfulness component is in the domain of emotional management. Adults with ADHD encounter coping difficulties in daily life that are often associated with strong feelings of frustration, distressing emotions (including boredom), and cognitions related to self-recrimination and pessimism that are highly disruptive to daily living and coping efforts. Even distractibility or problems focusing on a task can elicit strong reactions. Emotional self-regulation is already an area of difficulty for adults with ADHD and repeated frustrations are particularly difficult to manage. An acceptance strategy involves helping the individual with ADHD to recognize that there is a 100% relapse for ADHD symptoms—that is, even with the best coping skills, everyone encounters difficulties related to distraction, procrastination, disorganization, etc. Reminding patients that individuals without ADHD also have these difficulties helps challenge the all-or-nothing view of executive functioning and motivation. This view often reflects the distorted thought that adults without ADHD are able to pay attention and handle their affairs effortlessly. For adults with ADHD the issue is not whether difficulties will occur but how they are managed when they invariably do occur. Thus, acceptance helps handle the emotional response to these frustrations so that the problems are not magnified. The person with ADHD can notice and feel the frustration, but

Downloaded by [New York University] at 12:14 14 August 2016 can then refocus on the moment and decide how it will be handled. In addition to handling the emotional reactions to various frustrations, acceptance strategies also help manage the emotions experienced when anticipating tasks or when taking steps to face and get engaged in tasks. A degree of discomfort is normalized as part of the engagement process (i.e., “No one is ever ‘in the mood’ to study.”). The focus then turns to defining a discrete, valued behavioral objective, such as persisting on a task for a certain amount of time, which telescopes a goal down to a reasonable behavioral target to enhance follow-through despite some internal visceral discomfort. The approach is similar to a runner being unsure if he can last for his full route but who then refocuses on a more immediate target (e.g., “Let me just get to the top of this hill.”). 86 Models of Treatment Although mindful awareness is one aspect of larger mindfulness-based meditation training programs (Zylowska, 2012; Zylowska et al., 2008), the practice of pausing and reflecting on what one is doing and on whether it is consistent with one’s plans is a useful coping strategy. It is also consistent with cognitive interventions of monitoring one’s automatic thoughts. The nonjudgmental recognition of emotions is another mindfulness based, acceptance strategy that lends itself to an implementation focus (e.g., “I am feeling frustrated by this task and my jaw is tense. I will reread the instructions for the assignment and will stay on task for the full 10 minutes I agreed to work on it.”). Recog- nition and acceptance of emotions can help individuals refrain from automatically reacting to them. It is clear that a wide range of intervention strategies are needed to help individuals with ADHD manage its wide-ranging effects on their lives. It is very often a combination of the aforementioned interventions that allow the coping strategies to become more habitual, routinized, and automatic, thereby leading to sustained functional improvements in daily life. The next section reviews some of the common skill-based coping strategies used to manage adult ADHD. These coping domains and the implementation of the strategies are described in more detail in the companion workbook to this text. The workbook extends the discussion of these skills into various domains of adult life (e.g., college, workplace, relationships, health, and well-being) that go beyond the purview of our objectives here.

Speciﬁ c Interventions for Managing Adult ADHD

To-Do List The “To-Do List” section of interventions involves nested skills of defining, selecting, prioritizing, planning, and scheduling out what needs to be done in one’s life. Whether sorting through higher-ordered priorities, such as course selection or a job search, or the tasks to be done on a particular day, such as finding time to pick up items at the grocery store, the decision of how to devote one’s time and energy is an essential starting point in coping for most adults with ADHD. Executive dysfunction interferes with the ability to mentally hold and sort through the various tasks and demands of life in order to select and prioritize those that are most relevant for the current day. The process also involves strategically planning other tasks and responsibilities to be performed at points in the future, be it the evening of the same

Downloaded by [New York University] at 12:14 14 August 2016 day, later in the week, or a few weeks hence. All of these tasks require good organization and time management. Thus, externalization of information in order to list, organize, and then store information by using the Daily To-Do list and Daily Planner are foundational skills for time and task management. The Comprehensive To-Do List represents a “dump list” of all conceivable relevant tasks, from a recurring task, such as dropping off and picking up a child from school, to a longer range task that is not imminent but for which it is useful to record, such as refi- nancing a mortgage. The Comprehensive To-Do List can be divided into immediate, short-term, intermediate, and long-term tasks (or any similar system that makes sense for the individual). The specific coping skill can be personalized to the needs of the individual. For the most part, focusing on duties over the next 1 to 6 weeks will be sufficient Models of Treatment 87 for most people. The therapeutic elements of compiling this overarching list are (1) identifying planning itself as a discrete task to be performed, that is, it takes time to plan; (2) establishing a notebook or electronic file where the list will be stored; and (3) referring to and updating the list as an ongoing resource. The Comprehensive To-Do List provides a tangible and objective device with which to externalize the process of catching important ideas that come up and recording them for future consideration and planning. Many patients may have previously attempted to compile similar sorts of comprehensive task lists but abandoned them because they said it was overwhelming to see them all laid out together. The Comprehensive To-Do List is not an end goal in itself. The purpose of the list is to “unload” and record these tasks so that they can be strategically “forgotten” in daily life. Said differently, the Comprehensive To-Do List can be considered to be similar to an iTunes account that holds all media and apps. This comprehensive list provides a format for the recording and storage of useful information for later access without having to increase the working memory load or having to review it each day. Intermediate and long-term tasks can be filed away for later review. Time and effort can then be devoted to the plans and tasks that are immediately relevant, which are managed through the use of additional coping strategies, namely Daily To-Do Lists and the Daily Planner. The next level of To-Do List strategies is to establish a Daily To-Do List that is comprised of specific tasks that have been selected and prioritized from the Comprehensive To-Do List or that otherwise have been identified as relevant for a particular day. The Daily To-Do List represents a personalized collection of reminders of specific tasks that are relevant for the individual but that run the risk of being forgotten or avoided. These tasks are endeavors that require targeted effort to perform and that fall outside of the typical daily schedule, such as making a special stop at the grocery store on the way home from work, scheduling an appointment, attending an exercise class at a certain time, or working on a household chore or project. For example, a college student will not have to put his or her class schedule for the day on his Daily To-Do List, but his or her plan to go to the library during the break between classes to work on an outline for an upcoming paper represents a priority task for this list. The Daily To-Do List can also be used to identify specific tasks to perform that are at risk for becoming “lost in the shuffle,” such as returning an e-mail or running an errand. The Daily To-Do List also provides an opportunity to manage projects that are particularly associated with procrastination. A patient with ADHD noted that he had an

Downloaded by [New York University] at 12:14 14 August 2016 entry in his Comprehensive To-Do List titled “look into graduate schools” that is important to him but on which he has not taken action despite it residing on his Daily To-Do List for several weeks. We work with patients to help them define such tasks into specific, behavioral terms that increases the likelihood of getting engaged in them. This involves the coping skill of “breaking large tasks into their component parts.” Thus, the objective of “look into graduate schools” is more specifically defined as “spend 15 minutes doing an Internet search of colleges that have graduate programs in my field of interest.” Trans- forming the larger task into these more specific terms with manageable time commitments increases the likelihood of follow-through. This is but one small example of coping skills that adults with ADHD know to do, but by going through this process they are helped to actually implement them. 88 Models of Treatment Tasks that warrant a place on a Daily To-Do List should be recorded in some fashion to provide easy-to-access reminders for follow-through. We recommend that the Daily To-Do List be handwritten on an index card, back of an envelope, or other portable, easily accessible, and disposable means of providing a tangible reminder that can be carried with the individual. Smartphones and computer tablets also are an option for keeping a Daily To-Do List, although the concern is that while these devices are convenient and accessible, the seemingly small steps of taking them out, entering a passcode, and getting to the notepad feature may present enough of a barrier that the use of a paper To-Do List is more useful. We usually advise that only two or three tasks (and no more than five) be put on the list to keep it visually “uncluttered” and manageable. To further facilitate follow-through on tasks on the Daily To-Do List, it is recommended that specific times during the day be devoted to these priority tasks (with start and end times), akin to making appointments with oneself for the task. The tasks on the Daily To-Do List are most often competing with the various other commitments and responsibilities that occur during the flow of a day (e.g., work, school, family, etc.), which is another reason that individuals with ADHD are distracted from these priorities or forget about them. Defining a specific time for tasks, and having reminders on a To-Do List and Daily Planner also serve a priming function or cognitive rehearsal to carry out the task, such as the student who defines the time between classes as his “appointment” to study in the library until the time he has to leave for his next class. We have observed that the specific choreography of tasks in the course of the day is also an important consideration for many adults with ADHD. That is, the order in which tasks are performed and where they are situated in one’s day influences efficiency. Hence, an individual might prioritize and complete early morning exercise, which then facilitates improved attention and better follow-through later in the day. Other individuals build up engagement and momentum by completing a series of brief, low-priority tasks at the start of their day, thereby building confidence and competence that promotes effort on higher priority and/or more challenging tasks later on. Of course, one person’s adaptive choreography is another person’s recipe for disaster, so the utility of one’s approach must be honestly assessed to ensure it is a “good fit.” Scheduling specific times to perform tasks and developing an adaptive choreography of various tasks and commitments involves the use of the Daily Planner, discussed in the next section. Of course, developing the Daily To-Do List requires the prioritization of tasks. There is great flexibility in how one ranks and selects tasks to be performed. A three-level hier- archy can be used to identify high, medium, or low priority tasks, with some people

Downloaded by [New York University] at 12:14 14 August 2016 using color-coding to identify different levels of priority. The four quadrant approach in which tasks are rated as being high or low in urgency and importance (Covey, Merrill, & Merrill, 1994) provides an externalized format for assessing the relative priority of tasks. The goal of the quadrant model is to expend most effort on those tasks high in importance but low in urgency, which is a rubric for prioritization used by Solanto (2011) in her group CBT program for adult ADHD. The process of gauging the relative priority of different tasks helps to reserve sufficient time in one’s daily schedule devoted to higher- priority tasks. Of course, planning and prioritizing are tasks that require time to complete, something of which ADHD patients need to be reminded. Many adults with ADHD report being able to make lists and identify priority tasks but being unable to carry them out in a consistent manner. This complaint is consistent Models of Treatment 89 with the view of ADHD as a performance deficit. Hence, the Daily Planner is a tool and a process to increase the likelihood of accomplishing the tasks identified on To-Do lists within the flow of the myriad demands of daily life. Although the Daily Planner is the final step in the To-Do List coping strategies, it also represents a distinct coping strategy for adult ADHD.

Daily Planner Discussion of the use of a Daily Planner often requires a step back to help patients with the fundamental step of defining specific obligations, commitments, and tasks that will populate the planner. Many adults with ADHD end up adopting a reactive mode in which they wait for deadlines or crises to dictate what they need to do next rather than being proactive. In some cases, such as a recent college graduate or an unemployed worker who is looking for a job, the task is to impose structure or scaffolding on a day’s or week’s unstructured schedule that previously had been organized around school or work hours. Thus, while moving forward with developing a daily planning system in early sessions, many adults with ADHD will also be using the To-Do List and prioritization coping skills reviewed in the previous section. As an aside, the intricate sequencing of these coping skills sheds light on the complex workings and interactions of intact executive functions to achieve self-regulation in non-ADHD adults. The first step in the Daily Planner segment is choosing a planner system, which usually boils down to the question of “electronic or paper?” Apart from the rare instances in which someone consistently and regularly references the calendar feature on a computer, smartphone, or other electronic device, our anecdotal experience has been that a paper planner with sufficient space for scheduling is the preferred format. The capacity to lay it flat and opened on a desk and refer to it throughout the day increases its use and, consequently, its usefulness. Likewise, it seems that the act of handwriting tasks (as opposed to tapping buttons on gorilla glass) helps to encode information. The ability to view an appointment (including “To-Do task appointments”) within the greater context of the rest of the day, week, and month provides patients with useful and personal data about task commitments as well as a visual reference of the “choreography” of different obligations and how they fit together. Similar to the acquisition of a home exercise machine, the benefit of the Daily Planner is directly tied to how regularly and consistently it is used. The Daily Planner requires a commitment that it will be the central repository for the tasks, commitments, and other items

Downloaded by [New York University] at 12:14 14 August 2016 that represent how an individual with ADHD spends her or his time, effort, and energy. Once a Daily Planner has been selected, it is necessary to devote time to planning one’s schedule. We recommend establishing specific times dedicated to sitting down and working through a plan for the day. For most individuals, time at either the beginning or the end of the day (or both) is sufficient to establish a habit of thinking through and constructing the day’s plan and recording it in the Daily Planner. We suggest spending at least 10 minutes—an honest 600 seconds—for this task. Such a time frame is brief enough that it is a feasible undertaking but sufficient enough to think through one’s priorities and commitments. Framing the commitment as an “honest” 10 minutes emphasizes the importance of expending the full time and effort needed to plan one’s day, allowing the individual to ensure that the schedule is realistic, manageable, and well-defined. 90 Models of Treatment In fact, even when individuals have a relatively efficient scheduling system for keeping track of workplace commitments or family commitments, we find that the planning system is often underutilized. That is, patients who report that they use a planner at work or school often find that their discretionary time at home in the evenings and on weekends is disorganized, including follow-through on recreation or chores. For this reason, we encourage patients to use the Daily Planner to schedule odd jobs, exercise plans, errands, as well as protecting “downtime” in the evenings, activities on the weekends, and plans for the use of other less structured times throughout the day. For some college students or other young adults who are ambivalent about the need for such a formal scheduling system, we invite them to experiment with a planner by keeping track of valued recreation activities, such as intramural sports, clubs, or social events as a “foot in the door,” hoping they will later also record dates for upcoming exams and assignments that are due. We also emphasize that scheduling “downtime” is a perfectly legiti- mate activity to include as an entry in the Daily Planner. The Daily Planner provides a foundation from which to address that often elusive skill of time management that so many adults with ADHD pursue. The next section builds on the use of the Daily Planner to facilitate “time and task” management skills.

Time and Task Management Although concisely described as the issue of managing “time,” the broader issue in executive functioning and motivational terms is more accurately understood as the organization of behavior, effort, and energy across time. Hence, we use the phrase time and task management to encapsulate this range of coping skills. The Daily Planner is a tool that provides scaffolding in the form of a visual analog for the period of time in which an individual is organizing his or her behavior. We most often focus on a few days or a week at a time, though the skills are designed to be generalized to lengthier tasks and time frames. Setting up and implementing a plan is akin to a game of chess where understanding the moves of individual pieces is crucial, but it is the maneuvering of the different pieces as part of a strategy against an opponent that constitutes the actual game, that is, the implementation of skills. From a behavioral standpoint, the time spent planning one’s day is a form of cognitive and emotional exposure and rehearsal insofar as it represents thinking about tasks that need to be performed. Many priority tasks represent challenges and sources of anxiety or discomfort for adults with ADHD. In fact, many of them report the attitude that they do not like

Downloaded by [New York University] at 12:14 14 August 2016 feeling “bound” to a schedule, preferring instead to “go with the flow.” However, this outlook is a rationalization for escape from the discomfort that comes from facing challenges (e.g., “I have to be in the mood to work on that.”). Seeing as these individuals have already sought professional help for managing ADHD, there is likely evidence that this “go with the flow” approach has not been effective. In addition to facing rather than avoiding these tasks, daily planning and defining task engagement in specific behavioral terms represent cognitive rehearsal and “priming” actions that will promote subsequent follow-through. As we noted before and will repeat here, planning requires time and effort to perform. Spending at least 10 minutes devoted to setting out and reviewing the daily plan is our recommendation. This time frame seems sufficient for most people to identify and sort Models of Treatment 91 through priority tasks, items for the To-Do List, and to ensure the budgeting of adequate buffer time between commitments. Most people also find that this habit is a good one with which to start the day in a positive direction, rather than trying to plan what to do “on the fly,” which is akin to trying to tie your shoes while running. Some individuals have found that additional time spent at the end of the day, either at work or at home, developing the plan for the next day is helpful to them, both to wrap up the current day and to start priming themselves for the next day. Individuals in jobs with schedules that change throughout the day, such as emergency room physicians, salespeople, or stay-at-home parents, find that periodic schedule reviews throughout the day are required to make the necessary adjustments. In terms of the mechanics of time and task management, the first step is to populate the Daily Planner with all the known commitments, appointments, and obligations. These items include firm, time-based commitments (e.g., dropping off/picking up children from school, medical appointments, scheduled classes, arrival to work, scheduled meetings) as well as time-based, discretionary commitments (e.g., exercise, meals, sleep). The latter group of tasks represents self-care and recreational behaviors that respond well to being structured and habitual, but that are often sacrificed as a result of inefficiencies managing other commitments. The next step in time and task management is to transfer items from the prioritized Daily To-Do List into open slots in that day’s schedule in the Daily Planner. We encourage people to err on the side of underscheduling rather than overscheduling at the outset. When we review patients’ plans for an upcoming day or for a specific task, we pay attention to issues related to setting realistic expectations and to leaving adequate buffer times between tasks. In particular, it is important to define a reasonable task expectation for the time allotted (e.g., “I will spend 30 minutes thinking through an outline for my paper.”) or to allow enough time for commuting between appointments (e.g., “I will be driving during the evening rush hour, so I’d better plan to leave 30 minutes early.”). We advise defining specific start and end times for tasks that provide enough time “on-task” to be productive but not so long that the time commitment seems overwhelming, which will result in procrastination and avoidance. At the other end, having end times for tasks and transition plans helps decrease the likelihood of “overdoing” one task at the expense of another priority task, namely perseverating on one task to the detri- ment of another priority, that is, “hyperfocus.” Moreover, having a discrete end point helps to calibrate one’s motivation and effort rather than having open-ended expectations (e.g., “I can keep going for 15 minutes more.”). Implementation strategies are used

Downloaded by [New York University] at 12:14 14 August 2016 to manage the resumption of tasks after scheduled breaks or enjoyable activities that are vulnerable times for procrastination for many individuals (e.g., “If I find myself extending my break to avoid getting back to work on the report, then I will remind myself that I can get restarted by reviewing what I just completed before the break.”). Planning also works well on weekends or days in which there is little, if any, externalized structure and more discretionary time at one’s disposal. In fact, many adults with ADHD experience more difficulties during these less-structured times than during typical work or school days. Individuals who work from home, are self-employed, or are graduate students working on dissertations also face the challenge of having to construct a schedule with little, if any, externalized structure. The goal of the Daily Planner is to 92 Models of Treatment establish a “flow” to the day that will result in an increased sense of satisfaction and accomplishment from having spent one’s time and effort well. When there are unexpected changes to the plan, the Daily Planner provides a format for making the necessary modifications to accommodate the changes as well as any ripple effects for later plans, e.g., rescheduling commitments or informing someone you will be late. This function of the Daily Planner is akin to the saying that “you have to know the rules, so that you can break them”; in this case, you have to have a schedule, so that you can change it. Having an organized planning system does not make the events of life any less chaotic, but it provides a tool and a system with which to manage the chaos. What is more, the Daily Planner helps assess whether the chaotic event was, in fact, unpredictable or instead represents a factor that was underestimated, ignored, or simply forgotten. In addition to being a prospective tool to help organize the plan for one’s day, the Daily Planner also provides an important record of what was done and thus provides important feedback and information. How able was the person to adhere to the schedule? If there were difficulties, when did they occur? Could these difficulties have been anticipated? What can be learned from the schedule to improve future schedules? The Daily Planner provides a convenient record of what works and what doesn’t in order to increase the former and reduce the latter as part of treatment. One of the lessons learned by many adults with ADHD is that the order in which tasks are performed, or their choreography, is as important as the objective of fitting all the prioritized tasks into a day’s schedule. When helping adults with ADHD to keep their plans realistic (“Are you really going to wake up at 5 a.m. to exercise?”), a related topic is promoting an understanding of the importance of the timing and order of tasks within their schedule. For example, some people find an exercise routine significantly helps their focus and energy for the day, which increases the salience of morning exercise. Students may come to realize that there are certain times during the day that are more conducive to academic tasks than other times, such as the student who realized that it was better for her to work on writing tasks in morning hours rather than later in the day. Similarly, certain pivot points during the day might be devoted to certain tasks, such as going through the mail as soon as one arrives home from work, or checking e-mails after returning from a lunch break at work. These insights help individuals engineer their schedules to foster overall efficiency and “flow.” However, there will be cases in which circumstances do not allow for the ideal schedule, so adjustments can be made to adapt a daily plan accord-

Downloaded by [New York University] at 12:14 14 August 2016 ingly (e.g., “It is unrealistic for me to exercise in the morning before work; but exercise helps me, so I will plan to exercise after work.”). Reviewing the Daily Planner facilitates time and task management at two levels: first, it helps reinforce the plan for a particular day, serving as a cognitive rehearsal that primes the individual for the tasks ahead; second, the Daily Planner provides useful and personal feedback about the effectiveness of a plan as well as what works and does not work in terms of the timing of tasks. The amount of time spent in session working on daily planning is individualized. Some patients benefit from using time in session to work through a plan for the rest of the day and the next day after the appointment; other individuals review examples of time management skills in session and then implement them on their own as therapeutic homework. Models of Treatment 93 The use of the Daily Planner and time and task management skills themselves are tools that provide a blueprint or recipe for the day. However, similar to a blueprint or a recipe, if it is not followed, there is nothing to show for it. The next sections focus on the coping skills needed to help patients to implement these plans.

Getting Started Consistent with a theme we have repeated throughout this volume, many of our patients report they are good at coming up with schedules and plans but have difficulties executing them. Although it is highly beneficial to have a tangible Daily Planner that provides a visual cue for the day and for the flow of time and tasks, the space allotted to individual time frames and, in turn, tasks, is limited. In terms of time management, there might be a realistic time frame devoted to a task of “exercise” or “work on history paper.” However, when the time arrives to perform the task, individuals often end up procrastinating on getting started and run the risk of “running out of time” or avoiding the task, altogether. In many ways, we consider procrastination the most insidious feature of ADHD and a point of convergence for motivational and executive functioning skill deficits. In fact, procrastination has been called the quintessential self-regulatory failure (Steel, 2007). ADHD makes it difficult for affected individuals to develop, organize, and implement worthwhile plans over extended periods of time for which there is insufficient proximate reinforcement (or compelling negative consequences). Thus, getting started on such plans requires the ability to tolerate some discomfort in order to get engaged in tasks that are the building blocks for more distant objectives. Of course, these behaviors are not a strong suit of adults with ADHD. Consequently, individuals with ADHD describe frit- tering away time earmarked for exercise or working on a history paper, often with some sort of rationalization to ease feelings of guilt (“I’ll do it later”), but already having greatly decreased the likelihood of follow-through. The Daily Planner and spending time developing a schedule for the day is an important first step in getting started on tasks. Making a specific and time-limited reservation for a task within one’s schedule is an exposure task that requires the adult with ADHD to face a valued endeavor. The very fact that the task will be time bound (i.e., reasonable duration with start time and end time) creates realistic expectations and serves as a cognitive reframe to address anticipatory emotional discomfort, that is, “An hour working on the paper is not so bad. I still have the rest of the day for other things.” These sorts of “priming” tasks are designed to help individuals face tasks that they typically avoid.

Downloaded by [New York University] at 12:14 14 August 2016 Commonly, more specific, task-related preparations for getting started are required for these individuals. The experience of living with ADHD and its chronic effects often means that adult patients with ADHD have developed a problematic relationship with various undertakings important for adult life. That is, these individuals are readily motivated for tasks that interest them or for which they have developed a sense of competence that reduces the discomfort associated with them. At the same time, there are other tasks that elicit strong negative reactions that activate the procrastination cycle. Thus, when reviewing tasks within the daily schedule for which the adult with ADHD is vulnerable to procrastination, it is useful to start with a review of the person’s initial reactions to the prospect of performing the task (“What thoughts go through your mind when thinking about 94 Models of Treatment working on this task later today? What do you think will get in the way of your follow- through when you try to start?”). A first step in helping patients get started on a task is to review its importance or value to the person. Defining a person’s investment in an objective and tying the immediate task to that objective is a means for enhancing motivation. This feature also is emphasized in Acceptance and Commitment Therapy (Hayes et al., 1999) in order to define valued objectives (i.e., commitment) for which an individual is willing to endure some behavioral and emotional discomfort to achieve (i.e., acceptance). The ability to persist through short-term challenges to achieve a longer-term benefit is a feature of intact executive functions, self-regulation, and “grit” (Duckworth et al., 2007). Asking questions about the reasons the person wants to perform the particular task and, more specifically its role in longer-term plans, is a first step. The clinician can adopt a “Devil’s Advocate” position (telling the patient that you are doing so) and ask, “Why not just skip exercise today?” or “You still have a week until the history paper is due, why not just wait until the night before to get started?” in order to have the patient identify the adaptive reasons for investing the time and effort on the task. These questions also represent a cognitive intervention of gaining perspective and “de-awfulizing” a task, perhaps accessing positive emotional associations that will promote follow-through. Again, tethering these interventions to our understanding of adult ADHD, the goal is to help reduce the learned aversion to tasks and to enhance the motivation for follow-through by breaking down the tasks into manageable component steps. After explicitly defining and reinforcing these adaptive outlooks, it is useful to identify and anticipate the various barriers to task follow through and risks for procrastination that patients will encounter when they attempt to carry out their plans. The process of getting started on the plan (“task engagement”) is a particularly sensitive window of opportunity, so this step is emphasized in terms of developing implementation tactics: “Your plan is to leave for the gym (or start work on your history paper) at 10 a.m. on Saturday. What will be going through your mind at 9:59 a.m. on Saturday that might interfere with this happening? What will it be like to be in your skin then? What might you start doing that could result in not keeping to your plan?” The goal of this line of questioning is to help the adult with ADHD identify and make explicit the elements of her or his procrastination profile, to recognize them at the point of performance, and to develop implementation tactics to enhance follow-through (e.g., “If I tell myself that I want to go through my e-mail backlog before going to the gym, then I will remind myself that this is an escape behavior and that I will feel better once I start exercising.”).

Downloaded by [New York University] at 12:14 14 August 2016 The next step is to elaborate on the individual’s negative reaction to the task plan, despite the recognition of its value and role in larger objectives. Most often we have found that descriptions of the task are rife with magnification of discomfort and anticipated difficulties along with minimization of reward or satisfaction. These cognitive distortions are often quickly addressed with a review of evidence from past experiences (e.g., “You say that you feel too tired to exercise. Once you have gotten to the gym, have you ever fallen asleep on the equipment or seen others slumped over machines? Have you had to stop a workout to take a nap or do you actually feel more energized?” or “You say that you have to be ‘in the mood’ to do your school work. How often are you or other students truly ‘in the mood’ to do work? What are the types of things you can do to set up conditions in which you will be more likely to follow through on your work plan?”). Models of Treatment 95 Despite these cognitive and motivational enhancement interventions, however, some patients report that it still is difficult to get engaged in the task despite the knowledge of the logical reasons for doing so. Having a specific behavioral plan for task engagement augments the cognitive interventions in order to help the individual get started. This strategy involves taking the valued task as defined in the schedule (“go to gym” or “work on history paper”) and breaking it down into the smallest behavioral steps that will promote engagement and follow-through. Following the notion that “the whole is greater than the sum of its parts,” the patient with ADHD is prompted to break down the plan for task follow- through, emphasizing the discrete steps that will promote follow-through, what we described earlier as a behavioral script or recipe. It is useful to disentangle the cognitive and emotional reactions from the process itself and to focus on the component behavioral steps thereby making the task manual, something that the patient can “do.” For example, in the instance of going to the gym, the patient is queried about all the steps required to collect items needed for the workout. Hence, the behavioral script will focus on steps required to stop other tasks (e.g., turn off television) at the predetermined time, to walk upstairs and put on workout clothes, get keys, get into car, etc. Similarly, the plan for working on the history paper will start with going to a predetermined workspace, reviewing the syllabus to confirm the parameters of the assignment, spending 10 minutes organizing and outlining one’s thoughts about the next section to be written, etc. In this way, the first behavioral step in activating the desired behavioral sequence is emphasized (i.e., engagement). Thus, the behavior of standing up, turning off the television, and walking to get one’s gym clothes may initiate the “launch sequence” for exercise. Or a student finding and holding the notebook with the assignment and turning on a computer and opening the assignment file are important first behavioral steps in progressive exposure to the task that increases the likelihood of engagement. As an aside, time spent “thinking about” or “planning a task” represents a degree of cognitive and emotional exposure that can foster getting started on a task. Although it does not guarantee follow-through, the coping skill of being able to pause, think through a task, and break it down into a sequence of steps, particularly a first step, is an initial engagement task that helps adults with ADHD face a previously avoided task. Defining these sorts of micro-steps helps break down the elements of a task that would otherwise be overwhelming for adults with ADHD. These very small steps provide opportunities to develop further implementation plans for further engagement. These are the actions that individuals with intact executive functioning take for granted but which are

Downloaded by [New York University] at 12:14 14 August 2016 supremely challenging for adults with ADHD. Our version of the strategy of breaking down a large task into more manageable steps in order to get started is called the “10-minute rule” (Ramsay & Rostain, 2003) to provide individuals with ADHD an easy-to-remember “take away” reminder. ADHD adults often have unrealistic expectations for how long they will perform a task and will subsequently procrastinate because they feel overwhelmed by their own unrealistic expectations. For example, a college student plans to research and write a ten-page paper on a day during which he does not have classes (or has skipped a day’s classes in order to write the paper). This plan likely resulted from previous rationalizations for procrastination (e.g., “I don’t have to do it now. I’ll skip class on Thursday and will get it done in 1 day.”). 96 Models of Treatment As we point out to patients, we do not do tasks we enjoy for that long, much less a task as difficult as researching, organizing, and writing a long essay. What often happens, instead, is that the student keeps delaying starting the task because the time frame (e.g., several hours, “all day”) is unrealistic and daunting. Hence, the student engages in a series of rationalizations and escape behaviors (e.g., “I’ll watch this TV show, then I’ll be ‘in the mood’ to write,” or “I’ll take a nap first, then I’ll be rested and still have plenty of time to write,” or “After I eat lunch, then I will be focused.”), which culminate in not working on the paper at all. Thus, the student is left feeling frustrated but is still facing the fact that he must write the paper with even less time in which to do so. Instead, we ask, “What is the amount of time you could work on this task even if it ends up being as difficult and uncomfortable (e.g., distracted, cannot organize thoughts) as you anticipate it might be?” Usually the answer is somewhere around 10 minutes, hence our nickname for the intervention. The behavioral (i.e., implementation) task is to start working on the paper task for at least 10 minutes (600 seconds). The task is defined in behavioral terms, such as sitting in front of the computer with the file open and fingers on the keyboard, ready to type, at which time the clock starts. After those 10 minutes, the individual is encouraged to reassess the task. If the task turns out to be overwhelming or if he is unable to focus on it, then the student is permitted to stop working on it and to do something else without feeling guilty—the fact he was on-task for 10 minutes means that he did not procrastinate. We consider that action as an “informed decision” made by gathering information about the task and not the result of procrastination. Most often, however, after 10 minutes of engagement individuals have overcome their initial aversion to the task and are able to work relatively productively. Though not spending as much time on the task as was originally (and unrealistically) planned, individuals find that they are able to make reasonable headway on projects and gain satisfaction from staying on task, be it for 25 minutes, 45 minutes, or longer. Adults with ADHD gain confidence based on their hands-on experience once they get start working on tasks and using coping skills. Moreover, they are more likely to be able to return to a task at another time (still using task-engagement strategies) to continue working on it because it is less threatening once they have been able to face it effectively. In effect, the goal is to positively reinforce on-task behavior rather than negatively reinforce off-task behavior. However, should they find themselves again mired in procrastination, the “10-minute rule” provides a useful coping template that can be used to get back on task. The next section provides further discussion of maintaining on-task

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Keeping the Plan Going (Part 1): Motivation, Emotions, and Energy Most important tasks in adult life require ongoing engagement to manage or complete. Many projects cannot be completed in one work session, such as a large report for school or work, or a household repair project. There are many longer range objectives that require consistent performance to gain benefit, such as exercise, saving money, completing an academic degree program, or maintaining a household. These tasks require persistence of effort and energy over time in order to achieve the desired objectives, most often without immediate reward. Models of Treatment 97 Motivation is a term often used to describe the ability to persevere or persist toward longer-term objectives. Grit, another relevant concept, refers to “(p)erseverance and passion for long-term goals” (Duckworth et al., 2007). In fact, it is not lack of desire for the final goal that creates difficulties so much as inadequate persistence of engagement in the individual steps necessary to achieve the desired ends that is the critical issue for our patients. In terms of executive functions, motivation can be considered the ability to generate an emotion about a task that promotes task engagement in the absence of immediate reward/consequence and despite the experience of short-term discomfort (Barkley, 1997). From the standpoint of neurobiology, there are deficiencies in the availability of dopamine in the “reward centers” of the midbrain that interfere with maintaining a sense of motivation. Hence, although a college student knows and is able to state the importance of regular class attendance, doing so will require interrupting other, more immediately enjoyable or worthy but less time sensitive activities. As discussed in the previous section, there are prosthetic behavioral steps that can be taken to “manufac- ture” motivation in order to get started on tasks. In our experience working with adults with ADHD, certain endeavors in their lives are repeatedly associated with inconsistent outcomes and aversive emotions. These disappointments throughout life create barriers to getting started on certain tasks that magnify and are magnified by coexisting executive functioning and motivation deficits. Past episodes in which an individual devoted inordinate time and effort to schoolwork, work projects, or other tasks but that resulted in disappointing outcomes create a pervasive expectation that one’s effort will involve a great deal of discomfort for only disheart- ening results (e.g., “I spent hours every night doing homework just to barely pass—and sometimes I failed despite all my hours of hard work.”). Acknowledging and recognizing the influence of these past experiences on automatic negative emotional reactions to current tasks helps take an “invisible” and seemingly automatic process and make it a “visible” sequence of factors for the adult with ADHD. Elaborating these processes is a step toward disentangling the learned emotional reactions from the actual task at hand. The use of mindful awareness and acceptance of these uncomfortable emotions provides the individual with a coping template with which to recognize and make sense of the reactions without falling into the automatic emotional avoidance pattern of “if it feels bad, do something else.” The notion of “emotional hijacking” (or “amygdala hijacking”; Goleman, 1995) provides a way for patients to understand and remember how emotions set the stage for escape behaviors. Simply stating aloud how one is feeling at the moment helps reduce emotional reactivity on a neuro-

Downloaded by [New York University] at 12:14 14 August 2016 biological level (Lieberman et al., 2007). The purpose of these skills related to the awareness and acceptance of uncomfortable emotions is to kindle the notion that an individual can feel discomfort when facing a task and still follow through on the necessary behavioral steps to perform it. The cou- pling of emotional acceptance with basic behavioral steps to define a task (e.g., a behavioral recipe) facilitates task follow-through (e.g., “Can you still locate and open your notebook for class even if you are feeling stressed about the assignment?”). The use of mindfulness skills also emphasizes recruiting and bringing together one’s attention with a defined intention (Zylowska, 2012), which is congruent with our emphasis on implementation strategies. Multiple presentations of these concepts and skills, such as in the form of coping cards or coping statements (“no pain, no gain”), make the skills portable 98 Models of Treatment and more likely to be used. It will require time for adults with ADHD to build up their emotional endurance for managing uncomfortable emotions, but the process becomes easier when they observe that their investment produces positive results along with an increased sense of agency. Most importantly, coping skills and implementation plans gives patients concrete steps they can take in specific contexts to counteract their executive functioning and motivation deficits. A companion strategy for managing motivation mentioned earlier is establishing start times and end times for tasks. This places time limits on the task and sets realistic targets for handling the associated emotions (e.g., “I can handle one hour of studying.”). In addition to a reasonable time frame, time spent thinking through the benefits of the task also helps rebalance the ratio of aversion-to-motivation ratio (e.g., “The hour I study now is one less hour I have to study later. I’ve watched bad TV for more than an hour.”) and helps to arrange short-term rewards (e.g., “After I am done, I will be able to watch the game without having to worry about studying.”). Once the initial transition from being off-task to being on-task has been navigated, adults with ADHD have an opportunity to experience the visceral positive outcomes of task engagement, and to realize that the actual task is not as bad as was anticipated. Although the sorts of tasks with which adults with ADHD struggle are often not considered “recreational” or “pleasurable” tasks, patients often underestimate the degree of satisfaction that comes from task completion. Using a quote attributed to the author Mark Twight (cited in Ralston, 2004), “It doesn’t have to be fun to be fun.” Recalling some principles of the Daily Planner and of choreographing one’s schedule, it is important that individuals with ADHD recognize the effects of “energy management” on task follow-through. Procrastination is wearying. One effect of procrastination is that high-priority tasks demanding a certain level of energy and concentration to manage are deferred until later in the day or evening, when a person’s emotional and physical “battery” is probably low, thereby making it even more difficult to get activated on task. Thus, an aspect of personalized psycho-education about adult ADHD is helping patients determine the specific times during the day when they have the emotional reserves to devote to priority tasks. For example, a student might realize that she is better able to focus on reading assignments in the morning when she is “fresher.” On the other hand, there may be some mundane tasks, such as household chores, that can be adequately performed in “low battery” mode later in the day. Despite the benefits of making appointments in one’s own Daily Planner for tasks to organize unstructured time, many adults with ADHD find it difficult to follow through

Downloaded by [New York University] at 12:14 14 August 2016 when they know “no one is looking.” Externalizing reminders and motivational statements can be helpful in terms of activating positive emotions and coping skills associated with a task. Specific implementation strategy plans also are useful for handling these scenarios (e.g., “If I notice I am procrastinating, then I will go sit at my work sta- tion and use the 10-minute rule for the first item on my Daily To-Do List for work.”). That said, establishing accountability to others is another strategy for increasing task follow-through. CBT sessions or regular meetings with an academic counselor or ADHD Coach serve this function. Announcing one’s task intentions to a roommate or spouse, or sending an e-mail to a trusted friend, or posting on a social networking site (“I am going to spend the next 30 minutes organizing my closet.”) may help the person get started. Check-in meetings with a work supervisor or academic advisor are other Models of Treatment 99 externalized anchor points for chronicling and monitoring follow-through. Social obligations can infuse a task with emotional salience that provides a counterweight to the impulse to avoid. Of course, even when adequate preparations and plans are made for accomplishing tasks, individuals with ADHD nevertheless engage in procrastination. For example, an individual reports a recent positive experience with task follow-through, but encounters the typical cascade of difficulties making and executing plans to reengage in the next step on the same task the very next day. All of the behavioral skills and habits that serve as prosthetics for managing ADHD can help an individual approach the preci- pice of performing a task, but they also require the ability to make the final step to actually engage in the task. Consequently, we have found that the “in-the-moment” cognitions and attitudes about a task as well as overarching core beliefs and self-esteem all play a role in getting engaged (and reengaged) in tasks. This is the focus of the next section.

Keeping the Plan Going (Part 2): Attitudes, Beliefs, and Self-Esteem Although negative automatic thoughts do not cause ADHD, they play an important role in managing executive dysfunction and motivational deficits. More specifically, various cognitive processes influence emotional management, motivation (which we consider a specific form of emotional management), problem management and decision making, as well as task implementation. Simply recognizing and monitoring the role of one’s reflexive or automatic thoughts on experience is an important coping step. Because cognitions are so connected with emotional reactions, it is reasonable to conjecture that, similar to the finding that identifying and naming emotions reduces their intensity (Lieberman et al., 2007), identifying and naming cognitive distortions will similarly reduce their intensity. Cognitions and beliefs allow individuals to interpret and make sense of experience. The flow of cognitions and self-talk, akin to Freud’s notion of the preconscious, occur just out of awareness but are easily accessible by directing one’s attention to it. These reflexive thoughts are susceptible to becoming distorted; that is, incorrect or maladaptive conclusions are drawn about an event with insufficient evidence (e.g., “My friend did not call. She must be angry with me.”), or because of a biased interpretation (e.g., “I received a low grade on the assignment. It is because the teacher does not like me.”). In fact, after serving as an interpretation of the initial event, an automatic thought can turn

Downloaded by [New York University] at 12:14 14 August 2016 into the “event” for subsequent cognitions that magnify one’s reactions (e.g., “I’m supposed to meet my friend for coffee later, but if she is angry with me, I don’t want to deal with her. I’m going to skip the meeting.” Or, “There is no use studying for the midterm exam because now I’m sure the teacher already plans to give me a bad grade because he does not like me.”) (J. S. Beck, 1995). Cognitive modification interventions provide strategies for identifying the effects of cognitions on one’s experience and functioning, and for developing more adaptive outlooks, or at least deferring conclusions until more evidence is gathered. Even in cases in which the evidence supports an undesirable outcome (e.g., “My friend said that she is, in fact, angry with me because of a comment I made about her Facebook post.”), efforts can then be more usefully dedicated to handling the situation. 100 Models of Treatment As we pointed out earlier, positive thoughts are not necessarily adaptive, as when someone dismisses/discounts obviously risky behaviors (“I’ll use my rent money to go skiing this weekend. I’m sure my landlord will understand.”). The goal is to facilitate balanced outlooks that allow a person to follow through on endeavors and maintain options for handling situations. Adults with ADHD are more likely than non-ADHD peers to have had greater frustrations in many important aspects of life, often dating back to childhood experiences (Barkley, Murphy, & Fischer, 2008; Biederman et al., 2006). Hence, when asked for evidence supporting current negative interpretations, patients might accurately point back to past examples of frustrations and setbacks, such as failing a class, getting fired from a job, experiencing interpersonal difficulties, etc. As a consequence, many adults with ADHD have developed pessimistic attitudes about certain aspects of life that seem to them to be well-reasoned and accurate outlooks. We have used the metaphor of “invisible fences,” of the sort used to train dogs to stay within a certain property boundary, to describe the interaction of past experiences and cognitions on current functioning and coping efforts by adults with ADHD (Ramsay, 2011b). Adults with ADHD have experienced very real frustrations and setbacks in important life domains at various ages. Hence, negative interpretations and resulting pessimistic outlooks would seem to be incontrovertibly supported by the evidence of one’s experience (e.g., “I must simply be lazy,” or “I am not competent at handling the normal demands of life.”). Similarly, efforts at implementing changes in adulthood are often met with skepticism (“I’ve tried that before and it did not work.”) or abandoned at the first sign of difficulty (“The planner worked for a while but then I lost it and there is no sense in replacing it.”). Said differently, these outlooks and attitudes, spawned by frustrations that are the downstream effects of what is often undiagnosed and unrecognized ADHD, interfere with follow-through on reasonable endeavors and goals: what we have deemed “invisible fences.” Reapproaching these endeavors with an understanding of the presence and effects of ADHD is an important first step in the change process, akin to a “do over.” Recognizing and challenging one’s pessimistic outlooks in order to engage in tasks and to be resilient in the face of frustrations that come with living with ADHD are important skills with which to manage ADHD. We have found the use of various evocative metaphors and coping statements helps to increase the likelihood that adults with ADHD will remember specific coping habits and increase the chances these will be activated at the moment and point of performance. These metaphors represent cognitive interventions inasmuch as they present alternative and adaptive frameworks for the management of a variety of situations. As

Downloaded by [New York University] at 12:14 14 August 2016 mentioned earlier, the metaphor of the Defense Attorney to help develop adaptive cognitions is a useful one (Freeman & Reinecke, 1993). One of the most common cognitive distortions we have observed in adults with ADHD is that of comparative thinking, or measuring oneself against other people. Although there is a degree of social comparison that is a facet of human nature, comparative thinking becomes a distortion when these appraisals are unfair and maladaptive for one’s well-being. Adults with ADHD commonly assume that individuals without ADHD effortlessly manage the demands of life without having to exert effort to do so, such as using a planner, breaking down tasks, organizing and keeping track of items, etc. For example, an adult with ADHD might assume that a coworker seems to be able to arrive at work and start working without the need to spend 10 minutes developing a daily work Models of Treatment 101 plan and entering it in his planner. Consequently, the worker with ADHD has the thought “I should not have to work this hard to plan my day,” resulting in eschewing her planning time and subsequently having an unproductive day, thereby seemingly confirming her sense of inadequacy. There is a degree of truth to the view that adults without ADHD often do not have to work as hard to stay organized insofar as intact executive functioning makes it easier to do so. However, although it may require more concerted time and effort on the part of adults with ADHD to implement coping skills, they are the same skills employed by “free-range adults.” The adaptive view is that these skills are beneficial, represent good coping, and will likely help the adult with ADHD make progress toward personal goals. Moreover, it is likely that the coworker uses some sort of planning system that is not apparent to the observer. Overgeneralization is another common distortion among adults with ADHD. When there is a situation in which something goes wrong or a mistake is made, the consequences of this mistake are blown way out of proportion. Adults with ADHD, even with good treatment and coping skills, will continue to experience their fair share of mistakes, oversights, etc. that are characteristic of human nature, not to mention those directly associated with ADHD. Overgeneralization represents the effects of a single, circumscribed error activating excessive self-recrimination that if unchecked can lead to the onset of self-defeating behaviors. For example, an adult with ADHD, after recognizing that she lost a library book and would need to pay a fine, became very upset with herself, thinking “even young children keep track of their library materials better than I do.” She concluded that this mistake meant that she was “back at square one” and had not made any progress in her treatment. As a result, she skipped her medication for a few days, thinking “What is the point?” This is an example of how a rhetorical question can operate as a veiled automatic thought: In this case, “There is no point in trying to change.” Cognitive interventions focus on “reverse engineering” negative conclusions back to the original activating problem. The original problem offers an opportunity for skills practice: cognitive reframes for normalizing setbacks, for keeping these setbacks in perspective, and for examining the meaning of mistakes for the individual. A third and very common cognitive error among adults with ADHD is magnification and/or minimization. This distortion is particularly relevant insofar as it magnifies motivational deficits and interferes with task engagement. On the one hand, adults with ADHD often magnify the difficulties and disappointments they expect to encounter when taking on tasks. On the other hand, they minimize their ability to manage the task

Downloaded by [New York University] at 12:14 14 August 2016 as well as the benefits to be derived from facing the task. The magnification of negative outlooks often results in aversive emotions that, even in subtle forms, increase the likelihood of avoidance and procrastination. The target of cognitive modification in this case is to change the ratio of positive-to-negative expectations in order to garner enough motivation to get started. We use the metaphor of a legislative vote—a unanimous decision is not required to get started, rather the patient simply needs to garner enough “swing votes” to achieve a plurality in order to take the first step. Adults with ADHD are also prone to this distortion when assessing their progress in treatment and changes in their overall functioning. There is a tendency to magnify examples of ongoing coping difficulties and to minimize examples of improvement. This outlook also reflects a tendency to disqualify examples of positive changes and to focus on 102 Models of Treatment examples of ongoing problems. For the most part, change doesn’t happen in all-or-nothing shifts, but rather through gradual shifts in percentages. For instance, rather than skipping 40% of classes, a college student with ADHD skips 15% after starting CBT; or someone previously estimated that they procrastinated more than 50% of the time and now says maybe it is about 33%. Their problems haven’t disappeared but are trending in the desired direction. When someone dismisses these improvements, we use the reframe: “If you and I invented a medication that produced these changes, we would be billionaires right now” to illustrate that these behavioral changes are important and valid. Progress does not mean the absence of difficulties but rather an improved ability to manage them. A given automatic thought may often fit into several different categories of distorted thoughts, as they are not necessarily mutually exclusive. The primary objective is to view cognitions as reactions and assumptions that may benefit from further scrutiny if associated with excessive emotional reactions or coping problems. In addition to considering how a patient’s Defense Attorney would argue his or her case, other questions that can be used to help patients with ADHD regain perspective are the following:

• If a friend of mine (particularly one with ADHD) faced this situation and had this thought, would I hold him or her to the same standards to which I am holding myself? How would I how would I advise him or her? • Is there another way to think about this situation that will help me to manage it better? What could be the effect of changing my outlook? • Can I accept a degree of imperfection or discomfort in order to face this situation? Do things usually end up being as bad as I think they will? How will I feel in 5 minutes if I face this situation rather than avoiding it? • In the grand scheme of things, how significant is this situation? What is the worst that will happen? Will it seem this important to me in an hour? Tomorrow? Next week? Next year? How do I plan to handle it?

Although thinking is not doing, cognitions and verbal working memory (i.e., rule- governed behavior) play a role in executive functions, motivation, and follow-through. In particular, task-interfering cognitions for adults with ADHD (and the aversive emotions they engender) create strong barriers to follow-through on many coping skills. Hence, identifying and modifying maladaptive thoughts is a core component in CBT for adult ADHD to promote ongoing implementation and maintenance of adaptive coping skills. Thus far, we have focused on skills, strategies, and tactics that patients can use to man-

Downloaded by [New York University] at 12:14 14 August 2016 age and organize their endeavors. These are methods for enabling them to take action in their day-to-day lives that are likely to result in desired changes. The following sections address different ways to put these strategies together to manage different aspects of adult life. In fact, the next section focuses on ways to adaptively circumvent common problem areas, following the notion that trouble avoided is a problem solved.

Outsourcing Coping Skills A central focus of CBT for adult ADHD is helping patients proactively manage the myriad tasks and roles associated with daily life, that is, organizing and enacting behaviors across time. A related coping skill is outsourcing, automating, or otherwise delegating Models of Treatment 103 tasks in order to reduce the number of responsibilities that require direct management. In effect, this concept involves working smarter rather than working harder by institut- ing time- and effort-saving systems, such as automated payment for bills, automatic deposit of paychecks, and other software and apps for smartphones and tablets that reduce the coping load on the individual with ADHD. Even if some tasks cannot be completely automated, automatic reminders can be arranged for important dates, such as anniversaries, birthdays, etc. There are other responsibilities that can be outsourced by hiring others to do them, such as lawn care, bookkeeping, housekeeping, tax preparation, home repair, etc. If individuals are unable to afford hiring other people to perform certain tasks, we recommend bartering with friends to exchange services in a mutually agreeable manner (e.g., “I’ll mow your lawn for a month if you help me complete my taxes.”). Individuals may find that having a “shadow” or someone else who is present and doing the same task can be helpful, such as a student with ADHD finding a study partner. Arrange- ments with friends or family members can be made to tackle especially difficult tasks (e.g., “On Saturday we will go through and organize my closet and on Sunday we will organize your closet.”), and to share the burden of completing a difficult job. Even if a bartering arrangement cannot be established, setting up some form of external accountability is helpful (as noted in the section on dealing with procrastination). Stating one’s commitment to a sympathetic friend or family member about one’s intention heightens the salience of a task, as does making arrangements for a reminder and/ or for follow-up reports on the task. Check-in meetings with a supervisor at work or visiting a college professor during office hours regarding status of work projects or school assignments is another way to utilize available resources to increase task salience and follow-through. We should point out that there is a delicate balance between compiling a collection of useful outsourcing tools, particularly electronic ones, and chasing “fool’s gold.” That is, the aforementioned suggestions represent tools that help reduce the amount of time spent on various administrative tasks or household chores. On the other hand, a good deal of time and effort can be wasted searching for an “ideal” solution or continuing to use a tool that isn’t working. For example, many young adults insist on using their cell phones as the primary way of keeping track of time. However, their phones are often in their pockets and hence are not easily visible for quick glances. Having a visible time- piece (i.e., wristwatch) is a simple solution for keeping better track of time. Another example is that individuals might spend excessive time researching the “perfect” Daily

Downloaded by [New York University] at 12:14 14 August 2016 Planner or sorting through various organizational smartphone apps, which is rational- ized as being important but which actually functions to distract from other, more important, tasks. The crucial point is that the merits of a given coping tool are assessed by its ability to solve problems and improve functioning. Put differently, “sometimes simpler is better.”

Data Management Another area of difficulty experienced by adults with ADHD is managing all the data or information encountered in daily life. The basic take away message for managing information is “get it before you lose it.” The Daily Planner is a useful tool for recording 104 Models of Treatment information relevant for different appointments or tasks that are scheduled. Cell phones, electronic tablets, and electronic organizers can be used to record contact information for friends, family, professionals, and other important people. Different folders can be used to organize electronic files or e-mail files for easy access to important information. For example, one patient set up e-mail folders to track monthly automatic payments so that when they arrive in his inbox, he can simply drag-and-drop the notifications into their respective folders for easy access later on. Another strategy for managing automatic payments is setting up a unique e-mail account that is only used for finances and automatic payments. Similarly, traditional manila or accordion folders can be used to hold and organize bills and papers as well as workplace or school information for which there are hard copies. Many adults with ADHD benefit from reducing physical clutter by “going paperless.” That is, setting up electronic accounts, scanning important documents, and using digital media reduces the amount of physical “stuff” to manage. Electronic payments and other automated services help avoid some of the common consequences of poor time management and disorganization, such as late fees. Signing up for reminder systems for appointments, prescriptions, and any other important errands can greatly reduce stress. There will always continue to be organizational demands, such as making sure digital files are organized and patients can locate scanned forms. But going electronic is an important option to explore with patients. Having a paper notepad or notebook or other portable system for recording information is another useful strategy. A small notebook, electronic notepad feature, or sections in a Daily Planner for notes allows an individual to record important information for later transfer to a Daily Planner, electronic device, or other ultimate “home” for the data. This is a good coping strategy for patients who report being prone to getting off task when they suddenly think of something else they must do (though not necessarily at that moment). They should be encouraged to write it down in this notebook and then resume their work. A common barrier to using the aforementioned coping strategies involves thoughts along the lines of “I will look stupid pulling out a notebook and writing it down” or “The other person is busy and I do not want to waste her time while I write the appointment down in my planner.” These thoughts result in the person not writing anything down or, instead, writing brief, incomplete notes that result in confusion later. Using the reframe that investing a little extra time in that moment will avoid confusion and wasted time later, and challenging the original assumptions (e.g., “Would you react negatively if the other person pulled out a notebook and said, ‘I want to make sure I get this down?’”) help

Downloaded by [New York University] at 12:14 14 August 2016 to increase the likelihood of using the notebook. Moreover, simple communication strategies can be used to get accurate information, such as asking the individual to send a follow-up e-mail with the information (e.g., “I do not have my planner with me. Are you willing to send me an e-mail with the date and time of the meeting before I confirm?”). Similar strategies can be used in the workplace, such as requesting minutes from meetings or asking for follow-up e-mails regarding meetings or projects. College students have somewhat different data management challenges. Students benefit from taking notes during lectures to help stay engaged with the lecturer, which is a recommended strategy even when the student has access to a note-taking service as an accommodation. Lecture slides, notes, or summaries are often provided by an instructor but can be requested by a student in order to have diverse sources of information. Models of Treatment 105 Assigned readings are another source of information for college students. Many students with ADHD report that they reached college without being diligent about keeping up with assigned readings (or, frankly, not doing them at all), often stating that they were able to do well in high school by relying on notes, listening in class, or just “winging it.” Their approach to assigned readings often involves opening the book, starting at the first word of the first paragraph on the first page, and reading each line of text until reaching the final word or the final paragraph on the final page of the chapter. Not surprisingly, students with ADHD often report that their attention wanders, their eyes look at the words, but they do not “read” them, etc. This approach to reading may be difficult and inefficient for the student with ADHD, but it is continually used because it is all the student knows to do. An alternative and interactive reading approach is the SQ4R strategy (Forsyth & For- syth, 1993; Robinson, 1970). This approach involves actively interacting with the text and developing a framework for the topic rather than passively reading. The first step is to survey (S) the organization and content of what is going to be read. This process involves reading the title as well as any introduction to the text. The reader then scans the various boldface sections headings as well as the introductory sentences to these sections. The titles of illustrations, figures, charts, or other visual aids are read, as is the summary section. If there are end-of-chapter questions or bullet point summaries, these are reviewed, too. This survey provides the reader with a sense of the text to be read. Based on this survey, questions (Q) about the text are generated, often by creating them from the different sections headings. The text is read (R) one paragraph at a time with the agenda of answering the question posed at the start of the section. Note taking, such as recording (R) the answers to the questions or making notations directly on the text (or using note taking features in e-readers) helps keep the reader engaged and highlights important information for later review, akin to note taking in class, aiding attention (in some SQ4R models, this R denotes “reflecting” [Forsyth & Forsyth, 1993]). At the end of each section, the reader recites (R) the answer to the question posed or summarizes what was read, including summarizing aloud to reinforce the information. It may be necessary to look back in the text to fully answer the question. Finally, after completing the reading, the reader goes back through the sections to again review (R) her or his understanding of what was read. The combination of reading with a purpose, breaking the text down into sections, and rehearsing and reviewing information helps to increase focus and comprehension.

Materials Management Downloaded by [New York University] at 12:14 14 August 2016 In addition to difficulties managing conceptual information, adults with ADHD have difficulties managing tangible items or keeping track of the “stuff” of daily life. Although it may seem a nuisance symptom of ADHD, misplacing or losing important items can have serious, negative consequences. Problems negotiating the acquisition, organization, and disposal of possessions may result in clutter and disorganized living, work, or study spaces. The first principle of materials management is to establish a consistent location or “home” for important items. For example, having a defined place for setting down and retrieving one’s keys, wallet, purse, cell phone, work/student ID, etc. is often the first application of this coping skill. The behavioral task is to develop the habit of making sure to place items here upon arriving at the destination. This principle is akin to the 106 Models of Treatment mantra of “a place for everything and everything in its place” (e.g., Solanto, 2011). Through repetition, this coping strategy becomes more automatic and routinized. A similar approach can be used for dealing with incoming postal mail. Simply putting a shoebox or other receptacle near where mail is brought into a house or apartment helps keep it contained. The behavioral task is to develop the habit of sorting through mail on a daily basis to quickly discard “junk” or unnecessary items (“If I am not 100% sure I need this item, I will discard it.”). The remaining items, most often bills that cannot be automated, can be dealt with at a time scheduled in the Daily Planner. Similar to planning, organizing requires time. The overarching goal to “get organized” can be overwhelming. Identifying specific organizational objectives and defining the tools needed is a first step. For example, an individual may wish to keep track of monthly credit card statements, which reflects a specific coping target. The organizational tool depends on whether the person wants to do so electronically or by using the paper statements. If the choice is electronic, the person then needs to register an online account and keep track by scheduling monthly times to review his account or at least setting up reminders. If the person prefers storing paper statements, the person will have to define the type of “container” for the forms. An accordion or manila folder labeled with the specific credit card can be used and a location defined for where the folder can easily be found. Even a less elegant solution, such as a shoebox where all credit card statements are placed, can be highly effective. The benefit of a coping tool is assessed by its ability to solve a problem. One person might like to go to a specific folder for a specific credit card and be able to retrieve a statement that is filed chronologically; another person may prefer checking an online account; a third person is willing to grab the shoebox and go through all the statements from five different credit cards, taking comfort in the knowledge that “all my statements from this year are in here, somewhere.” A final point about material management systems is the consideration of their ease of use and maintenance over time. It is the implementation of an organizational system that helps someone stay and feel organized. Thus, there is choreography of different executive functioning strategies required to maintain good coping. For example, an individual may retrieve and sort through the day’s postal mail before doing other tasks (which reflects the implementation of an organizational plan). Upon seeing a credit card bill, the individual removes the payment stub and envelope and places it in the shoebox with other bills that will be paid at the designated time, say, on Sunday afternoon. How- ever, the filing of the paper statement requires the implementation of the steps required to carry it to the filing location for that purpose and placing it there. Although a seem-

Downloaded by [New York University] at 12:14 14 August 2016 ingly simple behavioral sequence, there can be various cognitive (e.g., “I do not feel like having to file this right now.”), emotional (e.g., feeling tired after work, mild stress associated with the bill), and behavioral barriers (e.g., habit of checking social networking site soon after arriving home) to doing so. As with most coping skills, the goal is to develop a sustainable habit that becomes increasingly automatic.

Environmental Engineering The concept of environmental engineering refers to using the awareness of the personalized effects of ADHD on daily coping and thereby redesigning one’s environment to be more “ADHD friendly.” There are some familiar suggestions for arranging, say, one’s Models of Treatment 107 bedroom to facilitate better sleep habits, such as not having work or study materials within sight of the bed, not using a laptop or other portable device that is illuminated with a type of light that interferes with melatonin production (Wood, Rea, Plitnick, & Figueiro, 2013) and distracts someone from sleep, etc. Many of the organizational systems discussed earlier will require defining storage areas in the house for files or other items that need designated “homes” in order to track their whereabouts more consistently. There may be personal sensitivities to distraction or stimuli (e.g., lighting, sounds) that affect patients’ decisions about the location of a work or study space within the home. It is an underappreciated option that specifying specific locations for certain tasks, most often work or study spaces reserved for specific tasks, can help to promote desired behaviors. Even a small desk in the corner of a room that is defined as a “study area” and has the necessary “tools” available can become associated with and operate as a cue for study behaviors. For example, one patient set up two desk areas in her home; one for her bills and other household administrative activities, the other for her professional activities. Such locations provide an individual with specific behavioral targets that can be used to overcome procrastination and task avoidance. In the spirit of “lowering the bar” to get engaged in a task, an individual may define an initial step as, “Let me first go and sit at my desk.” Similar principles can be used in a workplace setting, to promote exercise, etc. By doing so, these adaptive coping skills are reinforced and can increasingly become habitual and routinized, thereby requiring less effort to implement. Most people will likely have to make due with limited living and/or work spaces. Young adults might live in small apartments or share a bedroom, apartment, or house with roommates. Families may have children or senior parents living with them, which simultaneously reduces available discretionary space and increases the amount of “stuff” to be organized and stored. Workplace limitations might include working in an office with open cubicles, having a desk near a noisy hallway, or being a contractor working out of one’s truck. Similar to defining the tools needed for organization and devoting time to the process of implementing these tools, environmental engineering at home and work requires identifying the sources of recurring frustrations and considering options to reduce them. Thus, a worker in a cubicle can seek out an empty conference room or other closed office to reduce environmental distractions while working on a project. A contractor can use a portable, hard plastic file box to organize invoices or other papers for work, or may be able to organize them electronically using a computer tablet. Sometimes the solutions are as simple as closing a curtain over a window

Downloaded by [New York University] at 12:14 14 August 2016 while doing work at a desk to reduce distractions. Some tasks may be exported to other settings that are associated with productivity, such as studying at a school or public library or coffee shop. There may not be an ideal solution, but the important point is to find an adequate solution.

Problem Management/Decision Making This section addresses the issue of problem management and, in a similar manner, decision making. We use the phrase problem management instead of problem solving to highlight the idea that not all problems can be solved, or at least not in the manner an individual desires. One of the steps in problem solving is brainstorming possible 108 Models of Treatment solutions. When working with a man who had not paid his federal income taxes consistently over the past several years and who was being audited by the Internal Revenue Service (IRS), one of the possible solutions he generated was, “I will tell the IRS auditor that I have ADHD and maybe I will not have to pay the taxes or any fine.” This example of a “positive bias” notwithstanding, the situation is one that can be “managed” insofar as the man can execute a plan that will allow him to face and eventually move past the problem, although it won’t likely be “solved” in the manner in which he proposed. There is general consensus about the standard components of problem management. As with other interventions for adult ADHD, it is less the information about the steps involved in the process so much as ensuring that adults with ADHD use and externalize the problem management process when facing problems. The first step in the problem management process is defining the specific problem. Similar to defining tasks for the Daily Planner, this may seem simple, but in reality, there are often several separate problems involved in a given situation, each of which needs to be addressed separately. For example, the man mentioned above who faced an IRS audit presented his situation as one he was having troubles managing. However, when going through the first step of defining the problem, he presented the issue as, “I am getting audited by the IRS and I have not paid taxes for some of the years that will be reviewed. I have never been audited and I don’t know what to do. I told my wife that I had paid the taxes and now she will know I lied. She will be even angrier with me because money is tight right now and I don’t know how we will be able to pay back taxes or any fines.” It made sense that he was overwhelmed, but he presented at least three different problems to be managed that needed to be teased apart: (1) handling the IRS audit process, (2) disclosing the situation to his wife after he had deceived her, and (3) paying for back taxes and possible fines. His was an extreme situation, but the process of dismantling a large problem into separate, specific problems, each of which can be addressed through different means, is an important first step. After defining the problem, the next step in the problem management process is brainstorming potential solutions. The person is encouraged to think of any and all solutions to the problem without editing or eliminating options. A list of possible solutions or management options is compiled. After exhausting these options, the next step in the process is assessing the advantages and disadvantages of each option to construct a hierar- chy in descending order from most to least likely to be effective. In most cases, this step helps to confirm for the individual what needs to be done instead of procrastinating through rumination without action.

Downloaded by [New York University] at 12:14 14 August 2016 In some cases, such as with the man facing the IRS audit, the process yields an option with the highest likelihood of being effective, but the individual is ambivalent about executing it. This individual realized that the right course of action was to tell his wife about the audit and about his deception. However, he was worried about her reaction, felt extremely uncomfortable at even the thought of telling her the truth, and feared that she might divorce him as a consequence. He and his therapist reviewed the potential effects of not telling her and of having her learn about it from the auditor rather than from him. The option of “owning up” to his wife was framed as the “least bad” of the problem management options he had at his disposal. The reframe that “healthy” coping options are not always the most “comfortable” options was helpful for him. He prepared himself that he would have to accept that his wife would be upset with him for a while, Models of Treatment 109 perhaps several days or longer, but that it would be better if she heard the information from him rather than by some other means. The next two steps in the problem management process are implementing the best option and then assessing the outcome. From a clinical standpoint, it is useful to define in behavioral terms the implementation steps needed to enact the plan. In most cases, the plan is well- defined: “I will e-mail my professor to acknowledge that I did not hand in the paper on time. I will tell him that I will submit it before class tomorrow.” Facing problems, particularly when they emanate from difficulties associated with ADHD, will likely trigger patients’ negative thoughts about themselves along with feelings of shame that make them prone to subtle avoidance or to incomplete performance of a problem management option. For example, the man facing the tax audit delayed telling his wife, wondering if he could do so without facing her (e.g., e-mail), perhaps having someone else tell her (e.g., recruit a relative to tell her), or simply waiting for the elusive “right moment.” We identified that he assessed the “rightness” of the moment in terms of his anxiety about telling her and that, using this rubric, he would never encounter the right moment (akin to a student waiting to be “in the mood” to study). Instead, he defined the next adequate time that he could sit down with her and tell her. He and the therapist developed a script of the essential elements of what he needed to say to help him manage his anxiety and to help him follow through on what he had to do. For some problems, after assessing the outcome of what is considered the best option, it may be determined that the problem has not been adequately addressed. In such cases, there is an opportunity to reenter the problem management sequence to reassess possible options in light of any new information. Decision making follows a similar template. The first step involves defining the specific decision to be made. The next step is to define the different choices based on any limiting criteria (e.g., choosing from courses offered in a particular school semester that will fulfill academic requirements). The third step involves weighing the advantages and disadvantages of each option to identify the seemingly optimal choice. The final two steps involve implementing the decision and assessing the outcome. In many cases, there may be uncertainty about decisions that require more information to be gathered. For example, a high school student with ADHD has been accepted into two colleges and is uncertain about which one to attend. However, there may be additional information to be obtained that may help her differentiate between the options, such as availability of academic support services, size of school, etc. In some cases, individuals reach a point in the decision-making process where there

Downloaded by [New York University] at 12:14 14 August 2016 are several choices that are deemed acceptable, and yet the individual does not have criteria for ranking one over another and there is no other information to help make the decision. It could be a decision between two college courses offered on the same day, at the same time, with each course representing a topic of interest. The situation is akin to going to a restaurant and having difficulties choosing between two entrees. In the process of exploring this ambivalence, there are often thoughts and emotions associated with making the “wrong” decision. This reaction may be associated with the ADHD adult’s view that “I always make wrong choices,” or at least, “I do not trust my decisions.” The cognitive reframe in this situation focuses on the fact that “there is no way to make a wrong decision” based on the information at hand. The point is made that if the person chose one option and then his life could be magically rewound to that 110 Models of Treatment decision making point and the other option selected instead, each scenario could end up as having been viewed as a “good decision.” The focus turns to identifying what the person “feels” like doing, as an important role of emotions is to help individuals define what is important to them. A question posed to the patient, such as, “If I flipped a coin to make the choice for you, would you be rooting for the coin to land a certain way while it was in midair?” helps to identify hidden preferences. Part of the challenge of making decisions, particularly for adults with ADHD, is that it involves a degree of uncertainty. The sense of uncertainty is often associated with anxiety, which can be difficult for adults with ADHD to manage, resulting in short-term relief through procrastination about making a decision. Unfortunately, some opportunities will be lost if the person waits too long to make a decision, similar to a presidential pocket veto of a congressional bill—it is not actively rejected but it is functionally rejected when too much time has passed. We have offered the reframe that there are two levels of decision making. The first level is making the best decision based on the information available at the time. The second level is then “living the choice into being a good decision” by implementing it fully. If the choice is a class, it is made into a good decision by attending the class and following through with the work. If the choice is selecting a car, the choice is implemented by keeping up with scheduled maintenance and otherwise taking care of the car. To use a quote attributed to the United States Army General George S. Patton, Jr., “Make a decision and then do it like hell.” As can be seen, there are a wide variety of coping skills necessary for the management of adult ADHD. This fact also reflects how central the executive functions and motivation are to managing the myriad demands and relationships of daily life. The domains of coping skills are similar across different adults with ADHD, although the implementation in specific contexts will vary among individuals, and there will be different barriers to their use based on cognitive, emotional, and behavioral factors. Moreover, there are intra-individual differences in coping across developmental and situational contexts, such as levels of education, workplace environments, and family and relationship constellations. Different contexts make different demands on executive functioning and motivation. Space does not permit more detailed discussion of these interventions and other areas of coping difficulty for adults with ADHD, although these settings are addressed in the companion workbook.

CBT Summary Downloaded by [New York University] at 12:14 14 August 2016 CBT provides a clinically useful, evidence-supported framework for understanding the interaction of attitudes and behaviors commonly experienced by adults with ADHD. The basic tenets of CBT—that thoughts and beliefs exert significant influence on and are influenced by emotions, actions, and experiences, and that modification of these thoughts and beliefs leads to clinical improvements—are elegant in their simplicity, which leads most people to respond to descriptions of the CBT model by saying, “Of course.” However, identifying and disentangling candidate thoughts and beliefs and their influence of emotions and behaviors, and then structuring interventions so patients can develop new outlooks and have novel experiences that open up new possibilities in their lives, represents the crucial intersection of the science and craft of CBT. Models of Treatment 111 It is the consistent behavioral implementation of coping strategies to manage the effects of adult ADHD that is the most important marker of improved functioning and that provides the novel experiences referred to above. The insidious feature of ADHD is that it interferes with behavioral organization and performance across time. However, by developing these compensatory coping skills and being aware of the effects of ADHD, adults with ADHD can use and benefit from these strategies. Likewise, pharmacotherapy for adult ADHD can appear at first blush to be a straightforward undertaking, simply matching the correct medication at the right dose to treat the symptoms described by patients. However, issues of compliance, side effects, tolerance, and psychiatric and medical comorbidity complicate the practice of pharmacotherapy, as will be discussed in the next section.

Pharmacotherapy for Adult ADHD The most important step before starting pharmacotherapy for ADHD adults is thorough patient education. To begin with, the goals for using medications need to be clarified. This includes carefully delineating the target symptoms that are the focus of treatment (e.g., inattention, distractibility, restlessness, and impulsivity). Next, a method for measuring and keeping track of symptom change needs to be selected. We have found it useful to employ a medication log for this purpose (see Figure 2.2) in addition to standardized instruments like DSM symptom checklists, the 18-item Adult ADHD Self-Report Scale (Adler, Kessler, & Spencer, 2003), the Conner’s Adult ADHD Rating Scale (CAARS), or the Brown Attention Disorder Deficit Scale (BADDS) described in Chapter 1. Finally, a medication regimen needs to be chosen in keeping with patients’ individualized treatment goals, personal preferences, prior and current experiences with psychotropic medications, family members’ responses to medications, and comorbid psychiatric conditions. Once a medication is selected, both written and spoken information is provided to patients describing what is known about the mechanism of action of the drug, expected time course for clinical response, common side effects, and specific details about how and when the regimen will be initiated. Typically, this means starting at a relatively low dose, observing initial clinical effects, noting side effects, and setting a schedule for increasing the dosage to appropriate levels. Frequent follow-up visits are scheduled during the first few months to ensure that the patient has ample opportunity to discuss the positive and negative effects observed, and to address any questions or concerns that arise. Adjustments to the regimen are made according to the patient’s self-reports,

Downloaded by [New York University] at 12:14 14 August 2016 although it is important to solicit input from other observers (i.e., significant others). In most cases, stimulant medication is the first line of treatment. If a patient has had prior experience with a particular stimulant and found it to be helpful, we will start with that class of compound. If a negative response was obtained from one type of stimulant, we will try the other type of stimulant (methylphenidate vs. amphetamine). We prefer to start with longer- acting preparations of stimulants in order to simplify the regimen and improve adherence. A comprehensive list of medications and dosing guidelines can be found in Appendix D. If a patient experiences serious side effects such as cardiac symptoms, tics, mood instability, or severe insomnia, we will discontinue stimulant medication. Milder side effects can be addressed either via dose reduction or through the introduction of adjunctive medications (e.g. mirtazapine or clonidine for stimulant-associated insomnia). Close monitoring MEDICATION RESPONSE FORM Patient Name ______

Medication ______Dose, Schedule ______

Instructions: Please rate the following factors on a scale of 1–10 where 1 = poor, 5 = average, and 10 = excellent. Please write comments in the appropriate column.

Concentration Task Day Time Dose Attention Span Completion Mood Comments Downloaded by [New York University] at 12:14 14 August 2016

Figure 2.2 Medication Monitoring Form Models of Treatment 113 of vital signs, weight, and cardiovascular status at each visit is considered “standard of care.” Finally, failure of adequate treatment response, or evidence of inappropriate use (or abuse) are indications to switch the patient to a different class of medication. Atomoxetine is a suitable alternative to stimulants, particularly for patients who report high levels of anxiety, who are not comfortable with taking stimulants, and/or who report emotional dysregulation as a target symptom. As with stimulants, it is best to start at a low dose (e.g., 25 mg daily) and to increase slowly up to the target range of 80–120 mg daily. Taking the medication with meals reduces the occurrence of gastrointestinal side effects, and giving it at night minimizes the sedating effects. Unlike the stimulants, this medication takes up to 8–12 weeks to reach full effect, so patients need to be told not to expect rapid symptom improvement. If partial response is seen with atomoxetine, it is safe to add low-dose stimulant medication, particularly for daytime activities requiring greater concentration and freedom from distractibility. Alpha-2 adrenergic agonists (i.e., clonidine and guanfacine) are another class of medications that have been proven to be helpful for ADHD symptoms. Originally developed as antihypertensive agents, the long-acting preparations of these compounds are FDA approved as monotherapy for ADHD in children and adolescents. These medications are particularly useful in reducing hyperactivity, restlessness, impulsivity, and anxiety. Clonidine tends to be more sedating and shorter acting than guanfacine (approximately 4 hours versus 10 hours), but either agent can cause sleepiness and fatigue. Thus, they can be used to induce sleep in patients with ADHD and insomnia, regardless of whether the sleeplessness is related to taking stimulant medication or is simply a feature of the patient’s basic clinical presentation. With clonidine, we usually start with 0.1 mg at bedtime and increase weekly in 0.1 mg increments to a maximum of 0.4 mg, usually on a b.i.d. or t.i.d. schedule. With guanfacine, we begin with 1 mg at bedtime and increase by 1 mg increments (either once or twice daily) on a weekly basis to a maximum of 4 mg daily. Besides sedation, the most common side effects of these medications are dry mouth, headache, dizziness, and irritability. It is important to monitor vital signs and cardiovascular status on a regular basis, watching particularly for signs of hypotension, slowed heart rate, or irregular heart rhythms. Patients should be warned not to stop the alpha adrenergic agonists suddenly, since abrupt cessation can lead to serious hypertension, tachycardia, agitation, and excessive sweating. Of note, it is safe to use these agents in combination with stimulants, especially with patients who are experiencing “rebound phenomena” (i.e., becoming very restless and hyperactive when the stimulants wear off). If patients fail to respond to monotherapy with stimulants, atomoxetine, or alpha

Downloaded by [New York University] at 12:14 14 August 2016 agonists, we will try combining stimulants with alpha agonists, or stimulants with atomoxetine. Great care must be taken to monitor potential drug interactions, particularly any cardiovascular side effects. If combination treatments don’t succeed in reducing ADHD symptoms, we then turn to “second line” medications: bupropion, tricyclic antidepressants, or modafanil. We generally start bupropion XL at 150 mg daily and increase after 2 weeks to 300 mg daily if initial response is suboptimal. Headache, dry mouth, insomnia, and nausea are the most common adverse effects. Agitation or irritability is sometimes serious enough to warrant stopping bupropion. We usually use desipramine or imipramine at doses ranging from 150–300 mg daily or nortriptyline, 50–150 mg daily, with good results. If a patient reports excessive fatigue or other intolerable side effects, we will lower the dose before stopping 114 Models of Treatment the medication altogether. Close monitoring of EKG is mandatory, and any sign of cardiac rhythm disturbances is an indication to stop the medication. Modafanil can be used in doses from 100 to 400 mg, once or twice daily, as needed. We generally titrate upward on a weekly basis until a positive response is recorded. We will discontinue the medication if no positive results are seen at the maximum dose of 400 mg twice daily. Combining selective serotonin reuptake inhibitors (SSRI) with stimulants has shown to be useful for adults with ADHD and comorbid anxiety or depression. While any of the SSRIs can be combined safely with either methylphenidate or amphetamine, we tend to select the more sedating agents (e.g., paroxetine or sertraline) when patients report difficulty with insomnia or overactivation, and the less sedating compounds (e.g., fluoxetine or citalopram) when they complain of being too tired or underactive. When patients already taking an SSRI are looking for help with ADHD symptoms, adding a stimulant usually proves successful in reducing inattention, distractibility, impulsivity, and/or subjective feelings of restlessness. Since there is neither interference with hepatic metabolism nor any interaction between stimulants and SSRIs, we usually prescribe these at usual dosage strengths. To date, we have not observed any serious side effects from combined medication treatment, although occasionally patients will report feeling overly sedated. Patients with ADHD comorbid with anxiety and/or depression may find benefit from either venlafaxine or duloxetine, both of which are combined serotonin-norepinephrine reuptake inhibitors (SNRIs). With venlafaxine, we generally start with 37.5 mg of the extended-release preparation, and increase in increments of 37.5 mg every week or every other week up to a maximum of 225 mg daily. With duloxetine, we will start with 20 mg daily and increase in increments of 20 mg every week or every other week to a maximum of 80–90 mg daily. This gradual titration schedule is generally well tolerated and enables the patient to observe effects on both mood/anxiety and on ADHD symptoms. In cases where patients are already prescribed SNRIs but are complaining of difficulties with concentration or impulse control, we will start low-dose stimulant medication as an adjunctive treatment. It is essential that the patient be monitored for potential cardiovascular side effects (especially hypertension), and for signs of overactivation or agitation. Conversely, it is not uncommon for patients with partially treated mood or anxiety disorders to seek additional medical treatment for ADHD symptoms. In these circumstances, we try to maintain the patient’s current medication regimen while introducing an attention-promoting medication. For example, if the patient is being managed with an SSRI, it is our customary practice to initiate a trial of stimulant medication at the usual doses used for uncomplicated ADHD. If the patient is taking an SNRI, a trial of low

Downloaded by [New York University] at 12:14 14 August 2016 dose is indicated along with cautious monitoring of cardiovascular effects. Stimulants can also be added to bupropion with the similar precautions. In all of these situations, changes in both attentional measures and mood or anxiety levels should be monitored. If adding stimulants proves too difficult for the patient to tolerate, we suggest a trial of either alpha agonists or of modafanil. If these steps do not provide sufficient relief for ADHD symptoms, we will recommend starting the patient on a tricyclic antidepressant medication that will require weaning from SSRI or SNRI medications. Despite concerns about potential cardiovascular side effects, tricyclic antidepressants are very effective for depression and anxiety as well as for ADHD. Many patients come to appreciate the advantages of being on a single medication with multiple clinical effects. Lastly, when there is evidence of treatment-resistant depression along with prominent ADHD, a trial of an Monoamine Oxidase (MAO) inhibitor is certainly warranted. Models of Treatment 115 Special care must be taken with patients suffering from comorbid bipolar disorder. It is imperative that an extended period of stable mood has been achieved prior to introducing a stimulant medication. If the patient has been free of any manic or hypomanic symptoms for at least 3 months, it is reasonable to start the patient on a low dose of methylphenidate and observe their response. While many clinicians fear that stimulants can trigger a manic episode, this is actually a relatively uncommon occurrence. If and when it occurs, it is usually triggered by disturbances of the sleep-wake cycle. Coopera- tive patients can be instructed to watch for signs of insomnia, irritability, or impending hypomania and to contact the physician if any serious mood shifts are occurring. With respect to patients with active or recently active substance use disorders, we prefer to initiate ADHD treatment with atomoxetine, alpha agonists, or bupropion, and to avoid using stimulants. Once a therapeutic alliance has been established, and once the patient is reporting successful abstinence (backed up by clean urine tests), it is acceptable to introduce stimulant medication into the equation. Patients with comorbid sleep disorder, chronic pain syndrome, Tourette Syndrome, or autistic spectrum disorders require special pharmacotherapeutic approaches that are beyond the scope of this book. While there very few long-term studies of pharmacotherapy for adult ADHD, we have found that for most of our patients, medication effects remain evident for as long as they are prescribed. Of course, there are times when the dosage needs to be adjusted upwards, or when a previously effective medication seems to stop working. In these cases, it is important to help the patient to understand that alternative treatments are still available, and that loss of efficacy is not a sign that the patient is becoming “too dependent” or “addicted” to the medication. As before, the choice of using other medications must be approached using a cost-benefit analysis.

Pharmacotherapy Summary Despite public controversy regarding the use of medications, pharmacotherapy remains the most effective available treatment for ADHD regardless of the patient’s age. Stimulant medications stand out as the best studied, most widely effective first-line treatment option. Nonstimulant medications, including atomoxetine, clonidine, and guanfacine, have been shown to be effective alternatives, and are particularly useful for individuals who do not respond to or cannot tolerate the side effects of stimulants. Furthermore, cases that involve comorbid and/or complex psychiatric symptoms may require the choreography

Downloaded by [New York University] at 12:14 14 August 2016 of several different medications for adequate treatment. It is vital that medications used for the treatment of adults with ADHD be monitored frequently and suitably, including tracking cardiovascular status and measuring drug effects on sleep, appetite, and mood.

Chapter Summary In this chapter, we have provided detailed descriptions of both CBT and pharmacotherapy approaches for the treatment of adult ADHD. Each treatment makes a unique contribution to symptom reduction and improving the overall well-being of patients. Hopefully this chapter has provided clinically useful models for handling the “craft” of CBT and pharmacotherapy of adult ADHD. The next chapter is devoted to describing the current scientific evidence that forms the basis for recommending this integrative treatment approach.

3 Research Evidence for CBT and Medications for Adult ADHD

An increasing number of evidence-based treatment options are available for adult Attention- Deficit/Hyperactivity Disorder (ADHD), including psychosocial treatment, particularly cognitive behavioral therapy (CBT), academic support and accommodations for college students, workplace accommodations and support, relationship treatments, neuro- feedback, computerized cognitive training, and various complementary-alternative treatments. There is wide variability in the amount and quality of research support for these nonmedication treatments, which is an important consideration in treatment selection (see Ramsay, 2010b, for a review). It is important to recognize that medications are a viable option for treating ADHD symptoms and that there is a growing number of evidence- supported options to address the functional impairments and the challenges to well-being that lead individuals to seek help. It is clear that managing the symptoms of ADHD requires a truly bio-psycho-social approach to conceptualization and treatment. Medications provide the foundation of most treatment plans, with psychosocial treatments (i.e., CBT) being next most widely used treatment (Ramsay, 2010b). Empiri- cal support for pharmacotherapy, particularly the use of psychostimulants, has established medications as the first line of treatment to be considered for ADHD patients of all ages (Barkley, 2006; Dodson, 2005; McBurnett & Weiss, 2011; Rostain, 2008; Vitiello, 2009). Stimulant medications are the most thoroughly researched medications (not just psychiatric) prescribed to children. Although less widely studied in adults, the use of stimulant medications is well-supported by research as the most efficacious treatment of the core symptoms of ADHD available for adult patients. Other classes of medications have also been found to be beneficial for individuals who do not respond to or who cannot tolerate the side effects of the stimulants.

Downloaded by [New York University] at 12:14 14 August 2016 Currently, five medications have been approved by the US Food and Drug Adminis- tration (FDA) for the treatment of ADHD in adults. These medications include the stimulants Adderall XR ® (mixed salts of a single-entity amphetamine; Weisler et al., 2006), Concerta® , (methylphenidate hydrochloride; Medori et al., 2008); Focalin XR® (dexmethylphenidate hydrochloride; Spencer et al., 2007); Vyvanse® (lisdexamfetamine dimesylate; Adler et al., 2008); and the nonstimulant Strattera® (atomoxetine; Chamber- lain et al., 2007; Michelson, Adler, & Spencer, 2003). Several other medications that are approved for use in the treatment of ADHD in children and adolescents have been studied in adults with ADHD and are often prescribed “off label” for this population. These include amphetamines (e.g., Dexedrine® , Adderall® ); methylphenidate compounds (e.g. Daytrana® , Metadate® , Methylin® , and Ritalin® ); and the alpha agonists Intuniv® / Research Evidence for CBT and Medications 117 guanfacine and Kapvay® /clonidine (see Appendix D). Secondary options include medications that have had positive results in small N studies of adults with ADHD, such as tricyclic antidepressants, bupropion, and venlafaxine. There are clinical situations in which these medications are indicated, such as the use of bupropion in cases of comorbid depression and ADHD. Whereas many patients respond well to pharmacotherapy alone and will not require additional modes of treatment, mental health professionals often encounter cases that are more challenging and less responsive to medication management alone (Gualtieri & Johnson, 2008). Medication management for adult patients with ADHD is complicated by a number of factors, including presence of comorbid psychiatric and medical problems, selection of appropriate medication, tolerability versus effectiveness with chosen medication, and treatment compliance issues, including concerns about misuse and diversion of stimulants. Moreover, adult patients whose symptoms of ADHD have been mis- or undiagnosed until adulthood often present for treatment with severe functional problems affecting their well-being, multiple psychiatric comorbidities, and a complex assortment of ADHD symptoms, clinical challenges, and executive dysfunction that add several degrees of difficulty to treatment. Even with the positive effects associated with medication treatment, it has been estimated that pharmacotherapy alone is insufficient for upwards of 50% of adult patients (Wilens, Spencer, & Biederman, 2000). Moreover, improvements on measures of core ADHD symptoms provided by medications don’t always translate into satisfactory functional improvements (e.g., time management, organization, self-control, anger management). The findings from studies of the effectiveness of medications are very often based on responses to symptom questionnaires and on neuropsychological testing results. Although these are crucially important clinical data, improvements on these measures do not necessarily mean that the day-to-day well-being of these patients has adequately improved or that they will be able to carry out the necessary coping skills to manage their ADHD over the long haul. What is more, evidence-based clinical treatment of adult ADHD has moved beyond mere symptom improvement and is increasingly focused on the goal of remission as indicated by improved and stabilized effective functioning. Of course, “remission” in adult ADHD is not a static outcome but represents long-term “management,” akin to the notion of managing diabetes or any other chronic condition. Given that ADHD is a chronic and disabling condition, greater efforts are now being applied to reducing impairment and promoting successful coping as is seen with other chronic illnesses. Thus, the ongoing management of ADHD is an active, dynamic pro-

Downloaded by [New York University] at 12:14 14 August 2016 cess that needs to be adjusted at different points in adult life to account for new demands placed on executive functioning. The first edition of this book made mention of the “promise of psychosocial treatments for adult ADHD.” A 1997 review of treatment recommendations for professionals treating ADHD summarized the state of affairs for psychosocial interventions for ADHD adults as follows: “The data on psychosocial interventions in the treatment of adults with ADHD are entirely anecdotal” (American Academy of Child and Adolescent Psy- chiatry, 1997, p. 107S). It is safe to say that this “promise” has been fulfilled inasmuch as the psychosocial treatment of adult ADHD in the form of CBT is the nonmedication treatment option with the strongest evidence support (Manos, 2013; Ramsay, 2010b, 2011a) based on results from well-designed randomized control trials. These CBT 118 Research Evidence for CBT and Medications treatments target the very areas of functioning that are most relevant to each patient and provide useful coping skills and problem management strategies. In this chapter, we review published research on both psychosocial treatments and pharmacotherapy for adult ADHD in order to provide the evidence base for our integrative treatment approach. We start with a review of the psychosocial treatment literature.

Review of Research Evidence for Psychosocial Treatments for Adult ADHD At the outset of the 21st century, a panel of experts in the field of ADHD research and clinical practice was surveyed in order to establish treatment guidelines for ADHD (Conners, March, Frances, Wells, & Ross, 2001). One of the questions posed to the panel was, “In what ways do you feel that the current quality of ADHD (psychosocial) treatment in the United States could be improved? Give your highest rankings to the most important problems in the way that ADHD is currently being treated” (Conners et al., 2001, p. S-115). The experts’ four highest-ranked responses were, in descending order, “inadequate training in appropriate psychosocial strategies,” “inappropriate choice of psychosocial interventions,” “inappropriate duration of psychosocial interventions,” and “too little psychosocial treatment is being used.” These responses bring to mind Woody Allen’s monologue at the beginning of the film Annie Hall during which he tells of two women eating dinner at a Catskills mountain resort. The first woman complains that the food there is terrible and the second responds, “Yeah, I know, and such small portions.” So it was for the experts’ opinion regarding the state of affairs of psychosocial treatments for adult ADHD at that time: It was not being done well and there was too little of it. A computerized search of several psychological and biomedical research databases revealed that there are currently 20 published outcome studies of psychosocial treatments for adults with ADHD (and a few more ongoing studies not yet published) whereas there were only 8 when the first edition of this book was published (see Knouse & Safren, 2010; Manos, 2013; Mongia & Hechtman, 2012; Ramsay, 2010b, 2011a for additional reviews). Although the field may not yet be at a point at which it is ready to propose a set of empirically validated psychosocial treatment guidelines for adult ADHD, review of the different treatment approaches that have been studied indicates that there is a large degree of overlap and consensus regarding the essential components of treatment. The psychosocial treatment outcome studies reviewed here specifically focused on

Downloaded by [New York University] at 12:14 14 August 2016 adult patients with ADHD. Competent assessment strategies were used to make the diagnosis of ADHD. The majority of subjects were on concurrent medications for ADHD. Some collection of measures of ADHD symptoms, comorbid symptoms, and other markers of well-being were used to document treatment gains. The psychosocial studies reviewed here employed a variety of research designs. Several studies, particularly the earlier studies, used nonrandomized, open clinical study designs (including chart review) in which participants were assessed at both the beginning and end of treatment to determine if treatment was associated with clinical improvements. Such exploratory designs offer preliminary information about the clinical usefulness of a treatment; that is, whether or not the treatment studied was associated with clinical improvement. However, without comparing the treatment group to a control group, it is Research Evidence for CBT and Medications 119 impossible to assess if the treatment benefits obtained are greater than would be obtained by spontaneous improvement of symptoms or from other factors. Nonrandomized control studies compare a group of participants receiving treatment with a similar clinical group that is not receiving treatment, such as using a wait list control group. The use of a control group provides a comparison against which to judge the outcomes obtained from a particular treatment. However, without using random assignment to the respective groups, there is the possibility that extratherapeutic factors influenced the treatment outcomes, such as those participants consenting to be placed in the treatment group being especially motivated to follow treatment recommendations. Finally, randomized control studies provide the highest level of quality assurance of the studies reviewed. In these studies, a treatment group is compared with a control group and participants are randomly assigned to these groups. Consequently, it can be inferred with greater confidence that differences obtained between groups are the result of treatment interventions and are less likely the result of other factors. The purpose of this section of the chapter is to review the empirical basis for the CBT component of our combined treatment approach. Although several interventions included in the review were not explicitly described as CBT (e.g., cognitive remediation, thought-feeling-action), all the approaches described are consistent with the CBT model adapted for adult ADHD. Similarly, although considered consistent with traditional CBT, each of the research teams modified and expanded CBT approaches to make them relevant for the executive dysfunction and other functional impairments commonly faced by adults with ADHD. Thus, a review of the extant empirical support for CBT for adult ADHD also constitutes the state of the field of psychosocial treatments for adult ADHD. We have separated the approaches into either individual or group delivered treatments, and, within each section, we have differentiated randomized control studies from nonrandomized studies to reflect differences in levels of evidence .

Individual CBT Approaches Individual CBT for adult ADHD has the benefit of personalizing the treatment approach to the specific needs of the individual. When working with adults with ADHD, there is often a great deal of commonality related to the domains of executive dysfunction across patients. That being said, there are individual differences with regard to the barriers to implementing these coping skills, as well as in patterns of emotional and cognitive reactions to stress. The following studies represent research on individual CBT approaches

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Open and Nonrandomized Studies of Individual CBT Wilens et al. (1999) used a systematic chart review to study the effectiveness of an adaptation of CBT for adults with ADHD (McDermott, 2000, 2009). The participants in the study were 26 patients who met DSM-III-R (APA, 1987) diagnostic criteria for ADHD. All of the patients had received previous psychotherapy and 96% had some sort of lifetime psychiatric comorbidity. Of the patients included in the study, 85% received medications and CBT, concurrently. The length of CBT averaged 36 (+24) sessions over 11.7 (+8) months. The investigators obtained clinical measures at three time points: at baseline, at the point at 120 Research Evidence for CBT and Medications which medications were stabilized (for those on medications), and at the final clinical appointment. Wilens and colleagues’ results indicated that ADHD adults responded well to CBT and that psychosocial treatment augmented the positive response obtained from medication stabilization alone. At the point at which medications were stabilized (and before CBT was introduced), participants had significant improvements on measures of ADHD symptom severity, depression, anxiety, and ratings of overall functioning when compared with pretreatment scores. The combination of CBT and medications was associated with statistically significant improvements on ratings of severity of ADHD and anxiety symptoms, ratings of improvements on ADHD and anxiety symptoms, self- rated depression, assessment of overall functioning, and an ADHD symptom checklist (administered to 12 subjects). What is more, there was statistically significant improvement on ratings of improvement of ADHD symptoms associated with the completion of CBT (with medications) when compared with the point of medication stabilization. The addition of CBT was also associated with significant improvements on the other previously cited clinical measures when compared with the point of medication stabilization. Overall, 69% of the patients completing treatment had “much” to “very much” improvement in their ADHD symptoms based on clinician ratings. These findings suggest that CBT and medications form an effective combined treatment for adulthood ADHD that ameliorates both core symptoms and overall functioning. Rostain and Ramsay (2006c) conducted a prospective study of an approach that combined CBT for adult ADHD with medications (Ramsay & Rostain, 2003, 2008). The sample was comprised of 64 adult patients who underwent an extensive diagnostic assessment; analyses were conducted on the outcomes of the 43 patients who completed a course of combined treatment. Over 80% of the participants had at least one current comorbid disorder. The clinical measures obtained at the diagnostic assessment served as baseline data, and clinical measures were obtained again at the “end” of treatment, defined as the 16th session of CBT or at last contact, if earlier. The results indicated that the combined treatment was associated with statistically significant improvements on scores on the Brown Attention Deficit Disorder Scale (BADDS) total score and all five subscale scores (Brown, 1996), self-ratings of depression, anxiety, and hopelessness, and ratings of ADHD severity and of overall functioning. Thus, the combined treatment approach was associated with improvements in ADHD symptoms, depressive symptoms, anxiety symptoms, hopefulness, and overall functioning. Because the order of treatments was not controlled for, no conclusions regarding the

Downloaded by [New York University] at 12:14 14 August 2016 relative contribution of the individual treatments could be made from the data. The Rostain and Ramsay (2006c) study was originally designed to be an open study comparison of individuals seeking combined treatment, pharmacotherapy only, and CBT only; however, the vast majority of individuals chose combined treatment, render- ing the other groups too small for comparative analyses. A subsequent analysis of the CBT-only group yielded interesting preliminary findings, although one cannot draw strong conclusions from so small a sample (N = 5) (Ramsay & Rostain, 2011). Of interest was the fact that individuals with generally mild symptoms of ADHD (though fulfilling diagnostic criteria), mild and circumscribed areas of impairment, no or minimal comorbidity, average to above-average intelligence, generally stable life circumstances, good social support, who decline pharmacotherapy, may benefit from CBT alone for ADHD. Research Evidence for CBT and Medications 121 Significant improvements were obtained on measures of activation (BADDS Activa- tion), ADHD symptoms (BADDS Total), depression, and anxiety. There were trends toward significance on measures of attention, memory, overall functioning, and most measures of comorbidity. The finding of improvements in activation is consistent with the implementation focus and task engagement emphasized in this CBT approach for adult ADHD. An interesting finding from the Ramsay and Rostain (2011) study was seen in the demographic profile of subjects. There was greater ethnic-racial diversity among individuals seeking psychosocial treatment alone than was seen in those who completed combined treatment in the previous study. Reservations about the diagnosis of ADHD or about pharmacotherapy may represent potential barriers for help seeking for ADHD by members of minority groups (Waite & Ramsay, 2010). Consequently, individuals with such qualms might be more amenable to starting a course of CBT targeting their coping difficulties, thereby deferring the option of pursuing subsequent pharmacotherapy until the patient is more open to this option.

Randomized Control Studies of Individual CBT Safren, Otto, et al. (2005) conducted a randomized control study of a modular CBT approach for adults with ADHD on stabilized medication regimens who were experiencing ongoing residual symptoms (Safren, Perlman, Sprich, & Otto, 2005). Safren and colleagues’ CBT approach is composed of three core modules, with sessions dedicated to organizational, planning, and problem-solving skills (module one), reducing distractibility (module two), and cognitive modification (module three). Optional modules are available to address anger management, relationship issues, and procrastination. Subjects were randomly assigned to either CBT (with ongoing medication management, n = 16) or continued medication management only (n = 15). Participants completing CBT had improvements on ratings (using both self-rating and independent raters) of ADHD symptoms, depression, anxiety, and global functioning. Individuals in the CBT group were four times more likely than those receiving pharmacotherapy alone to be full treatment responders (56% v. 13%), further suggesting CBT makes a distinct contribution to the treatment of adult ADHD. Safren and colleagues performed a follow-up randomized control trial of their CBT approach compared with an active treatment control: relaxation training (Safren et al., 2010). Eighty-six adults who were diagnosed with ADHD with clinically significant

Downloaded by [New York University] at 12:14 14 August 2016 symptoms despite medication treatment were randomly assigned to either CBT or relaxation-education treatment. Both treatment groups received 12 individual meetings of 50 minutes each, so all participants received equal exposure to treatment. Outcome measures were obtained at baseline, end-of-treatment, and at 6- and 12-month follow-up intervals from the start of treatment. The treatment completion rate was 91.9% and 81.4% based on subjects who completed the respective follow-up assessments. At the end of treatment, subjects in the CBT group had better scores on an ADHD rating scale and blind ratings of overall functioning than subjects in the relaxation group. The CBT group also had a greater rate of improvement in the weekly current symptom self-ratings than did the relaxation group. There were significantly more treatment responders in the CBT group than in the relaxation group and, among those 122 Research Evidence for CBT and Medications subjects in the CBT group who at least partially responded to treatment, these gains were maintained at follow-up assessments. Thus, Safren et al. (2010) demonstrated that their manualized CBT program outperformed another active treatment approach for adult ADHD. It should be noted that review of the outcome data indicated that individuals in the relaxation group also improved in treatment and reported maintenance of gains at follow-up, but to a lesser degree than those in the CBT group. Virta et al. (2010b) conducted a randomized controlled trial of individual CBT compared with cognitive training exercises for adults with ADHD. Forty-six individuals were diagnosed with ADHD by a study clinician and enrolled in the study. The subjects were randomly assigned to one of four groups: CBT, computerized cognitive training, hypnotherapy, or wait list control group. The published study did not include the hypnotherapy group, leaving 29 subjects, with 10 each in the CBT and control groups and 9 in the cognitive training group. About half of the subjects were taking prescribed psychiatric medications during their participation in the study, mostly for ADHD. CBT consisted of 10 weekly, 1-hour individual sessions adapted from a group CBT approach (see Virta et al., 2008). Cognitive training involved twice-weekly, 1-hour training sessions, resulting in 20 hours of computerized training targeting attention, executive functioning, and working memory. Results indicated that individuals completing CBT reported improvements on the BADDS Total, Attention, and Memory scores as well as on a work/study scale in a quality of life inventory. The results were stronger than obtained in the control group, although there were no significant differences between groups in neurocognitive performance. The cognitive training group exhibited improvements in the skills involved in the training program, but they did not generalize to other neurocognitive measures or to various clinical inventories of ADHD symptoms, mood, or functioning (although there was improvement seen in the BADDS Affect scale). When comparing the two active treatments, the results indicated that those subjects completing CBT achieved greater clinical improvements than did those in the cognitive training group. Weiss, Hechtman, and the ADHD Research Group (2006) developed a nine-session, manualized problem-focused therapy (PFT) approach that was examined as part of a larger randomized, placebo-controlled, parallel group study comparing paroxetine, dextroamphetamine, their combination, and placebo in a sample of adults with ADHD. Of the 98 adult subjects entered into the protocol, 23 were assigned to PFT + medications, and 25 were assigned to PFT + placebo. The primary outcome measures were a measure of ADHD symptoms, an investigator rating scale, and a measure of functional impairment. PFT was included in the study to increase retention of participants and to justify the

Downloaded by [New York University] at 12:14 14 August 2016 use of a placebo group. PFT sessions were coordinated with study medication visits and focused on psycho-education and on employing effective coping strategies using a modular approach. While concurrent medications (i.e., dextroamphetamine) and PFT were associated with a significantly higher number of treatment responders, participants receiving PFT + placebo demonstrated augmentation over time on measures of overall improvement, mood and anxiety symptoms, and ADHD symptoms. Weiss et al. (2012) performed a planned secondary analysis of their PFT described above. That is, treatment subjects were randomly assigned to either PFT + medications (i.e., dextroamphetamine) or PFT + placebo. Both subjects and investigators were blind to treatment group assignment. In particular, the researchers were interested if medications enhanced the therapeutic effects of psychosocial treatment for adult ADHD. Research Evidence for CBT and Medications 123 Treatment followed the PFT manualized approach: nine sessions of individual treatment initiated after the medication regimen was stabilized. Patients were seen every other week for the first seven sessions and then twice for monthly booster sessions, cov- ering a total of 20 calendar weeks. Although manualized, the specific skill training approach was adjusted to the “critical problem” chosen by the patient as the therapeutic agenda for the meeting, striking a nice balance between structuring and personalizing treatment. Outcome measures were obtained at baseline, Week 15, and Week 20. Results indicated that 63% of patients improved (i.e., > 25% improvement in investigator ratings) and 47% of patients normalized. The effect size for amelioraton of ADHD of symptoms was large and for ratings of functioning was moderate. There were no statistically significant differences between the measures of symptom or functional improvements obtained by the PFT + medication and PFT + placebo groups. However, the authors were cautious, making the point that failure to find a difference is not the same as equivalence. Although individual treatments provide many distinct benefits to adults with ADHD, group CBT treatments provide another valuable option with many unique benefits to participants. The next section reviews outcomes research on group CBT approaches for adults with ADHD.

Group CBT Approaches Group CBT approaches for adult ADHD have the benefit of allowing clinicians to help a greater number of patients than can be achieved with individual treatment. Moreover, there are positive effects for participants interacting with peers who have had similar experiences. This setting allows for recognition of the common difficulties faced by individuals with ADHD as well as mutual support in the coping process. The following studies represent research on various group CBT formats for adult ADHD.

Open and Nonrandomized Studies of Group CBT Wiggins, Singh, Getz, and Hutchins (1999) examined the effectiveness of a four-session psycho-educational group composed of nine adults diagnosed with ADHD. A group of eight adults with ADHD who did not receive group treatment served as the control group. The authors described the theoretical approach for the group as focused on the reciprocal relationships of thoughts, feelings, and actions. The goal of this paradigm was

Downloaded by [New York University] at 12:14 14 August 2016 to help participants more systematically and effectively implement behavioral changes in targeted-skill domains pertinent for managing ADHD symptoms. Pre- and posttreatment measures included an unpublished 68-item symptom checklist that identifies seven problem areas commonly associated with ADHD: self-esteem, hyperactivity, interpersonal difficulties, disorganization, impulsivity, emotional lability, and inattention. The groups were conducted in four 90-minute sessions that focused on participants’ difficulties related to setting realistic goals, organization/time management, task completion, and managing their environments, respectively. Results indicated that there were statistically significant decreases on three of the seven domains of the symptoms checklist: disorganization, inattention, and, interestingly, self- esteem. These results suggest that subjects who completed the group treatment reported 124 Research Evidence for CBT and Medications improved organization, improved attention, and counter-intuitively, lower self-confidence. The authors interpreted the latter finding by suggesting that adults who experienced longstanding functional difficulties associated with ADHD might experience transitory lowered self-esteem when finally facing the magnitude of their symptoms in treatment. This interpretation is consistent with our clinical observation, although this hypothesis was not examined using follow-up measures to confirm that participants’ self-esteem did, in fact, later improve. Significant differences also emerged between the treatment and control groups on posttest scores. The treatment group’s scores on subscales measuring disorganization, inattention, emotional lability, and self-esteem were significantly lower than were those for the control group, indicating that participation in group treatment was associated with improvements on measures of organization, attention, emotional stability, but also lowered self-esteem. Hesslinger et al. (2002) examined a structured skills training program (Hesslinger, Philipsen, & Ricther, 2004) in a group format adapted from the dialectical behavior therapy (DBT) for borderline personality disorder (Linehan, 1993). The modified DBT approach involves breaking down treatment for ADHD into 13 specific skill-based modules. The groups were conducted in weekly 2-hour meetings for 13 consecutive weeks, each session devoted to a single module. Written materials and daily exercises were part of the treatment regimen. A total of 15 patients were selected based on meeting DSM-IV (APA, 1994) diagnostic criteria for ADHD. Eight patients agreed to participate in the group. Seven adults who were placed on a wait list for the group served as the control group. There were no significant differences between the treatment and control groups with regard to age and gender, and their pretreatment clinical measures were described as being “well matched.” Only three of these controls were available for follow-up, however, and all of them had started some form of medication treatment by that time, compromising any reasonable interpretation of group differences with the treatment group. The results indicated statistically significant improvement on a measure of mood, the self-rated ADHD checklist, a set of items from a larger symptom checklist that were relevant for ADHD, and self-ratings of overall personal health status. Furthermore, patients who completed the group showed improvements on neuropsychological tests measuring selective and split attention. Patients’ evaluations of treatment were generally positive, and the group format was rated as being the most helpful aspect of treatment, followed by psycho-education, the therapists, and the skill-building exercises, in descending order. There were no changes in the medication management of ADHD in the treat-

Downloaded by [New York University] at 12:14 14 August 2016 ment group, thus the treatment effects are not attributable to medication effects. Hesslinger et al.’s study is also notable because it integrated mindfulness and neurobiology as a discrete treatment module. Researchers are starting to investigate the effectiveness of mindfulness-based coping strategies in the treatment of ADHD (e.g., Zylowska et al., 2008). The positive results from this pilot study of DBT for adult ADHD were used as the basis for a multicenter follow-up study of its efficacy (Philipsen et al., 2007). Seventy- two patients with adult ADHD were seen at four different centers. Completion of treatment was associated with statistically significant improvements on measures of ADHD, depression, and personal health status. There were no differences in treatment response as a function of either treatment site or medication status. Sessions topics of behavioral Research Evidence for CBT and Medications 125 analyses, mindfulness, and emotion regulation were rated by participants as being most helpful. Of important note, outcomes are being analyzed for the largest, strongest, and most comprehensive study of psychosocial treatment for adult ADHD based on this DBT approach (Philipsen et al., 2010, 2013). The sample of 419 adult patients in multiple sites in Germany is comprised of virtually equal numbers of males and females, with 57% diagnosed with the combined type of ADHD and 66% with at least one lifetime Axis I disorder. Subjects were randomly assigned to one of four treatment arms: DBT + medication (12 weekly DBT sessions followed by monthly follow-up sessions for 10 months), DBT + placebo, clinical management + medication (12 weekly sessions followed by monthly follow-up sessions for 10 months of psychological counseling without behavioral interventions), and clinical management + placebo. This design allows for the assessment of the distinct contributions of medications and psychosocial treatment to the clinical outcomes observed in a large sample of adults with ADHD. Solanto, Marks, Mitchell, Wasserstein, and Kofman (2008) assessed the effectiveness of a manualized group CBT program for ADHD adults. The explicit targets for the intervention approach were various areas of impairment associated with executive dysfunction, namely time management, organization, and planning (ON-TOP). Thirty adults (18 females; 12 males) completed either 8- or 12-week versions of a weekly, 2-hour CBT group program and completed both pre- and posttreatment measures. The majority of treatment completers met diagnostic criteria for ADHD predominantly inattentive type (70% vs. 30% combined type) based on clinical interview and responses on the CAARS. Coexisting psychiatric diagnoses were common, with 63.3% presenting with comorbid depression and 43.3% with comorbid anxiety. Medication status remained stable during the study, and there were no outcome differences among participants who were or were not medicated. Treatment duration did not affect the outcomes. Solanto and colleagues’ results indicated that treatment completers exhibited significant improvements on the Conners’ Adult ADHD Rating Scale (CAARS; Conners, Erhardt, & Sparrow, 1999) subscale measuring DSM-IV Inattentive Symptoms (with nearly half of the sample reporting posttreatment scores below clinical threshold), BADDS total scores, and a 24-item self-report questionnaire developed by the researchers to measure of various executive function skills (i.e., TOPS). There was no statistically significant improvement on the CAARS subscale score measuring DSM-IV Hyperactive-Impulsive Symptoms, although this result may be an artifact of the over representation within the sample of participants with the predominantly inattentive type.

Downloaded by [New York University] at 12:14 14 August 2016 Virta et al. (2008) reported the outcomes of 29 adults who completed a CBT-oriented group rehabilitation program comprised of 10 or 11 weekly 1½- to 2-hour sessions administered to four groups of six to eight participants each. The interventions were aimed at reducing symptoms and impairments associated with ADHD and other manifestations of executive dysfunction. Outcome measures included self- and observer-ratings and were gathered at initial assessment, at the start of the first group meeting, and at the end of the final group meeting. There was no difference in participants’ self-reports during the 3 months between assessment and start of treatment, which allowed participants to serve as their own controls. After completing treatment, however, there were significant improvements on measures of activation, attention, and affect regulation. 126 Research Evidence for CBT and Medications Salakari et al. (2010) performed a 6-month follow-up study of the Virta et al. (2008) study. Of the 29 adults who completed group CBT, 25 (86%) were available for 3- and 6-month posttreatment follow-up assessment. Participants who had reported improvements at the end of treatment in ADHD symptoms maintained most of these improvements at follow-up. Improvements in other psychiatric symptoms were also maintained at follow-up, but to a lesser degree. Overall, 72% of subjects rated their overall functioning as being “somewhat” or “markedly improved” at follow-up compared with their pretreatment baseline functioning. Bramham et al. (2009) tested a 6-week CBT group program for adults with ADHD (e.g., Young & Bramham, 2007; 2012) that targeted issues related to anxiety and depression, low self-esteem, and self-efficacy. Sixty-one adults (40 males, 21 females) attended the CBT group, though 20 participants dropped out before the end of the program. A group of 37 adults with ADHD (21 males, 16 females) who received medication only from the same center served as the control group, although the groups were not randomly assigned. The CBT group’s first and last sessions focused on psycho-education about living with ADHD. The middle four sessions addressed different topics or modules at each meeting: anger and frustration, emotions, relationship skills, and time management and problem solving. Participants completing the CBT group reported significantly improved knowledge about ADHD when compared with the control group. Both CBT and control groups reported improvements on measures of anxiety and depression, though there were no between-group differences. The CBT group reported significantly improved self-efficacy and self-esteem when compared with the control group. Participants rated sharing of personal experiences of living with ADHD as the most valued aspect of group CBT, although it was not rated significantly higher than other aspects of the group.

Randomized Control Studies of Group CBT Stevenson, Whitmont, Bornholt, Livesey, and Stevenson (2002) performed a systematic evaluation of the efficacy of their cognitive remediation programme (CRP). The CRP specifically targeted problems commonly associated with ADHD in adulthood: attention problems, poor motivation, disorganization, impulsivity, anger management, and low self-esteem. Subjects were assigned to either a CRP group (n = 22) or a wait list control group (n = 21). Medication status remained stable throughout the study, with participants being either unmedicated or on a stable, effective dose. CRP was provided

Downloaded by [New York University] at 12:14 14 August 2016 in 8 weekly 2-hour group sessions. A clinical psychologist facilitated the groups with the assistance of “coaches” who helped participants complete various exercises. The results indicated that, after treatment, participants reported improvements on ADHD symptom checklists, organizational skills, self-esteem, and anger management skills. These treatment gains were either maintained or continued to improve at 2-month follow-up. Significant treatment gains in ADHD symptoms and organization were maintained at 1-year follow-up. Despite these improvements, the authors hypothesized that additional interventions might be needed to achieve more substantial and sustainable improvements in self-esteem and anger. Stevenson, Stevenson, and Whitmont (2003) conducted a follow-up randomized control study of a self-directed version of their CRP for patients, with minimal therapist Research Evidence for CBT and Medications 127 contact. Participants in the study were randomly assigned to either the CRP group (n = 17) or wait list control group (n = 18), and there were no significant differences between groups on pretreatment clinical measures. Medication status again remained stable throughout the study, with participants being either unmedicated or on a stable, effective dose. As in the previous study, participants were paired with coaches, but this time, the coaches’ role was to contact participants weekly by telephone and remind them to keep up with the therapeutic assignments and to use the CRP self-help book they were given. Coaches also monitored compliance with the program. There were also three therapist-led sessions at the start, middle, and end of treatment to monitor progress. Outcome measures were obtained at baseline, end of treatment, and 2-month follow-up. All outcome measures (e.g., ADHD symptoms, organizational skills, self-esteem, and both state and trait anger) showed significant improvements for participants completing CRP treatment when compared to pretreatment scores and with controls. At 2-month follow-up, CRP-related treatment gains were maintained for ADHD symptoms, organizational skills, and trait anger. Forty-seven percent of CRP participants were considered treatment responders in terms of ADHD symptom reduction at the end of treatment, and 36% were responders at 2-month follow-up. Analyses of treatment compliance revealed that participants generally followed the program outline, and there was a significant and positive correlation between compliance and treatment outcome. Thus, not surprisingly, participants who followed the CRP treatment program experienced greater improvements than did participants who did not. Solanto and colleagues (2010) conducted a follow-up randomized controlled study of their metacognitive group CBT approach in which the treatment was compared with a supportive, psycho-educational group program. Eighty-eight adults with ADHD were stratified by medication use status and otherwise randomly assigned to either metacognitive (n = 45) or supportive group therapy ( n = 43). Groups were comprised of six to eight participants and met for 12 weekly, 2-hour sessions. Outcome measures were obtained immediately pre- and posttreatment, employing blind evaluator assessments (Adult ADHD Investigator Symptom Rating Scale [AISRS]; Adler, Spencer, & Bieder- man, 2003), self-reports, and observer-reports. More specifically, the AISRS and CAARS Self-Report inattention/memory problem subscale were the main outcome measures. The CAARS Observer-Report and an anxiety scale score also were obtained. The posttreatment results indicated that group CBT outperformed the support group on independent evaluator ratings of inattention as well as time management, organization, and planning skills. In fact, the more severe the pretreatment ratings of inattention,

Downloaded by [New York University] at 12:14 14 August 2016 the greater the improvements achieved through CBT as compared to the support group. Collateral ratings of inattention and memory problems (as measured by the CAARS Observer-Report from) also were more improved for the CBT group than support group. There were improvements on other measures of executive functioning associated with the CBT group, but these were not statistically significantly greater than those achieved by the support group. Neither treatment produced improvements on measures of comorbidity. In terms of response to treatment, 42% of CBT group participants (as compared to 12% of support group participants) were considered treatment responders based on achieving 30% improvement on independent ratings of inattention symptoms; 53% of CBT participants (versus 28% of support group participants) were considered responders 128 Research Evidence for CBT and Medications based on achieving at least one standard deviation improvement on CAARS Self-Report of inattention and memory problems. Similar to the findings associated with the CRP (Ste- venson et al., 2003), completion of therapeutic homework exercises was significantly associated with clinical improvements. Emilsson et al. (2011) conducted a randomized controlled study of the Reasoning and Rehabilitation for ADHD Youths and Adults program (Young & Ross, 2007). Fifty-four adults with ADHD who were being treated with a stable medication regimen but who continued to exhibit clinically significant symptoms were randomly assigned to either the CBT group or a treatment-as-usual condition. Outcome assessments were obtained at pretreatment baseline, end-of-treatment, and at 3-month follow-up, including independent ratings and self-reports of ADHD symptoms, impairments, and comborbidities. The manualized group CBT program consisted of 15, twice-weekly sessions (90 minutes each) divided into five treatment modules focused on a variety of coping issues related to ADHD. It was derived from a 35-session program developed for training individuals in a correctional facility. It included both group and individual treatment elements, the latter achieved through the use of trained “coaches” who helped participants make use of their coping skills in daily life during weekly 30-minute meetings. The treatment-as-usual condition involved ongoing medication treatment alone. Results indicated that there were significant improvements in ADHD symptoms at the end of treatment associated with the addition of group CBT to a stable medication regimen. Moreover, there were large effect sizes for ADHD symptom improvements at 3-month follow-up, except for milder improvements in the hyperactivity/impulsivity symptom domain. There were similar improvements in comorbidity (including antisocial behaviors) at the end of treatment that were even better at follow-up, indicating that a benefit of CBT is the ongoing access and use of coping skills. Hirvikoski et al. (2011) conducted an independent replication of the previously discussed DBT group program modified for adult ADHD. Fifty-one adults with ADHD who were on a stable medication regimen (or no medications) were randomly assigned to either a specialized group for adult ADHD ( n = 26) or a mini-structured “discussion” group ( n = 25). The specialized ADHD group was comprised of 14 weekly, 2-hour sessions. Treat- ment followed a published treatment manual (Hesslinger et al., 2004) modified for the Swedish setting where the study was conducted. Group sizes were comprised of four to eight participants. The control group condition also involved 14 weekly, 2-hour sessions in order to ensure equal exposure to treatment. Accurate psycho-education was pro-

Downloaded by [New York University] at 12:14 14 August 2016 vided when participants asked questions and a problem solving-approach was adopted when specific problems were discussed in the group, but group leaders did not provide “interventions,” instead encouraging participants to generate solutions along with providing them with support, encouragement, and positive feedback. Results indicated that completion of the group approach modified for adult ADHD was associated with moderate improvements in ADHD symptoms (effect size = .57); completion of the control group was not associated with symptom improvement. Neither group treatment was associated with improvements on measures of comorbid symptoms. Sub- jects in both groups were satisfied with treatment, and both treatments were feasible based on 82% session attendance rates. The specialized ADHD group program scored higher in ratings of credibility. It should be noted that nearly half of the study sample (45%) was Research Evidence for CBT and Medications 129 unemployed, indicating the subjects had more severe functional impairments than is typically seen in psychosocial treatment outcome studies for adult ADHD.

Miscellaneous Psychosocial Treatments Although not within the purview of CBT, as part of the recruitment for the Virta et al. (2010b) study listed above, subjects were recruited for a study of hypnotherapy in a sample of adults with ADHD compared with controls (Virta et al., 2010a). Nine subjects were randomly assigned to receive hypnotherapy and compared with the same control group used in Virta et al. (2010b). Seven of the nine hypnotherapy subjects were being medicated for ADHD. Hypnotherapy involved 10 weekly, 40- to 60-minute individual sessions. Treatment followed a semi-structured manual in which the theme of each session focused on a domain of difficulty common to adult ADHD (e.g., initiation of tasks, memory, attention). Results indicated that individuals in the hypnotherapy group exhibited greater improvements than the control group on self-report of ADHD symptoms, either reaching or approaching significant differences on BADDS Total, Attention, Activation, and Memory scales, self- report of ADHD symptoms, and the work/study scale in a quality of life inventory. There was no effect of treatment on neurocognitive functioning as measured by the CNS-Vital Signs program. Although not a CBT program, the Virta et al. (2010a) study provides more evidence that treatment programs specifically designed to target functional problems associated with adult ADHD may have some additional benefit. Langer, Greiner, Koydemir, and Schütz (2013) evaluated a stress management program designed for adults with ADHD. Eighteen adults with ADHD were recruited from a German psychiatric clinic for a four-session (3 hours each) stress management program. There were two groups comprised of nine participants each. All participants completed pretraining questionnaires that measure coping styles and perceived chronic stress. Posttraining measures included the perceived chronic stress questionnaire and a relaxation and well-being inventory. An investigator-developed inventory provided an assessment of changes specific to the focus of the interventions, namely knowledge acquisition and implementation. Participants were also asked to rate their individual achievement of at least three goals they set at the start of the program. There was also an overall evaluation of the training process. Results indicated that at pretraining, participants scored significantly below the mean for coping style scale’s normative sample on the positive coping style of “denial of guilt”

Downloaded by [New York University] at 12:14 14 August 2016 and significantly above the mean for all negative coping styles. Participants’ scores on measures of perceived chronic stress all fell at least one standard deviation above the normative mean for the scale, indicating high stress. Posttraining indicated that participants had significant improvements on the ratings of demands at work, worry, and chronic stress screening on the perceived stress scale. Partici- pants completing training also had improved relaxation and well-being ratings and made 50% progress on their training goals, on average. Trainees rated the program in the “good- to-excellent” range and found various aspects of the training very acceptable. The unique aspect of this study is that it put stress management at the forefront of treatment. Treatment of college students with ADHD has emerged as a specific intervention domain. An open study of an 8-week, CBT-informed Coaching model for college students 130 Research Evidence for CBT and Medications with ADHD was conducted with 148 college students over 5 years (Prevatt & Yelland, 2013). Results indicated significant improvements on the 10 learning and study strategy domains measures and on measures of self-esteem, life/work satisfaction, and symptom distress. Lastly, Anastopoulos and King (2014) examined a CBT and mentoring program for college students with ADHD comprised of group CBT and individual mentoring sessions. An open study of 43 undergraduate students was conducted, 95% of whom had been diagnosed with ADHD before going through screening for the program. After several iterations, an 8-week program was developed that is feasible to deliver within a semester and that can be augmented by a maintenance phase during the subsequent semester. The active treatment involves 8 weekly 90-minute group sessions and eight 30-minute individual mentoring sessions. Maintenance phase involves two booster group sessions and five or six 30-minutes individual mentoring sessions. Preliminary findings from the CBT/mentoring program indicated significant improvements in ADHD knowledge, use of organizational skills, and reductions in maladaptive cognitions. There also have improvements on measures of ADHD symptoms, executive functioning, educational benefits, emotional well-being, and use of campus services and resources. Most of the CBT approaches reviewed in this chapter can easily be adapted for use with college students or other specific groups of adults with ADHD (see Table 3.1).

Table 3.1 Published Peer-Reviewed Outcome Studies of Psychosocial Treatments for Adult ADHD

• Wiggins et al. (1999)—Psycho-educational group for adult ADHD • Wilens et al. (1999)—Chart review of CBT + medications • Hesslinger et al. (2002)—DBT modular group treatment • Stevenson et al. (2002)—CRP group treatment • Stevenson et al. (2003)—Self-directed CRP group treatment • Safren, Otto, et al. (2005)—RCT of individual CBT • Rostain & Ramsay (2006c)—Individual CBT + medications • Weiss et al. (2006)—RCT of individual PFT • Philipsen et al. (2007)—Multisite DBT modular group treatment • Solanto et al. (2008)—CBT group treatment • Virta et al. (2008)—CBT group treatment • Bramham et al. (2009)—CBT group treatment • Safren et al. (2010)—RCT of individual CBT vs. active treatment

Downloaded by [New York University] at 12:14 14 August 2016 • Solanto et al. (2010)—RCT of CBT group treatment • Salakari et al. (2010)—Posttreatment follow-up of Virta et al. (2008) • Virta et al. (2010b)—Individual CBT vs. cognitive training • Emilsson et al. (2011)—RCT of CBT group treatment + individual coaching • Hirvikoski et al. (2011)—Independent replication of modular DBT group • Ramsay & Rostain (2011)—Individual CBT for patients not taking medications • Weiss et al. (2012)—Follow-up RCT of individual PFT

Note : ADHD = attention-deficit/hyperactivity disorder; CBT = cognitive behavioral therapy; CRP = cognitive remediation programme; DBT = dialectical behavior therapy; PFT = problem focused therapy; RCT = randomized controlled trial. Research Evidence for CBT and Medications 131 Psychosocial Treatment Summary The clinical outcome research on psychosocial treatments for adult ADHD has greatly improved in both number and quality of studies since the first edition of this book. There are 20 peer-reviewed studies of CBT-oriented approaches for adult ADHD with 9 being randomized control trials. These numbers include the forthcoming results from the study of CBT for ADHD and substance use disorders and the recently completed multisite study of DBT for adult ADHD from Germany. The latter study will likely stand as “the MTA study for adult ADHD,” in reference to the largest treatment outcome study examining the treatment of children with ADHD (MTA Cooperative Group, 1999). Based on the available empirical evidence, it is fair to say that CBT stands alongside medications as the treatments of choice for adult ADHD. An encouraging outcome of the extant research on CBT for adult ADHD is that there are multiple treatment approaches that have been shown to be effective. There is a great deal of overlap of the different treatment programs that have been studied in terms of the coping skills used to treat executive dysfunction, motivational deficits, and various impairments associated with ADHD. Moreover, there are several published treatment manuals and session guidelines to help community clinicians to implement treatment with their patients. CBT for adult ADHD can easily be employed at the same time as medication treatment, which has been found to be an effective combination for many patients. The next section will review the treatment approach for adult ADHD with the strongest research support for its use: pharmacotherapy. We will review the empirical evidence for the use of the variety of medications to treat adult ADHD that were discussed in the last chapter. This review will include the primary, secondary, and tertiary medications for adult ADHD as well as available support for off label use of other medications that have been found to be helpful in some clinical situations.

Review of Research Evidence for Pharmacotherapy for Adult ADHD Empirical studies of pharmacotherapy for adults with ADHD are not as numerous as those for children and adolescents, however, there is now a growing consensus regarding practice parameters to assist clinicians in prescribing medications. The American Academy of Child and Adolescent Psychiatry (AACAP; 2002, 2007), National Institute for Health and Clinical Excellence (NICE; 2008/2103), Canadian ADHD Resource Alliance (CADDRA; 2011), Brit- ish Association for Psychopharmacology (Bolea-Alamañac et al., 2014; Nutt et al., 2007), and European Network Adult ADHD (Kooij et al., 2010) practice guidelines as well as other Downloaded by [New York University] at 12:14 14 August 2016 reviewers (Dodson, 2005; McBurnett & Weiss, 2011; Rostain, 2008; Santosh, Sattar, & Canagaratnam, 2011; Volkow & Swanson, 2013) all recommend the use of stimulant medications (i.e., methylphenidate- or amphetamine-based compounds) as well as nonstimulant medications (e.g., atomoxetine, guanfacine, clonidine, bupropion) with less consensus regarding the use of tricyclic antidepressants (e.g., desipramine, nortriptyline) and SNRIs (i.e., venlafaxine, duloxetine). The particular choice of initial medication depends on numerous factors including the patient’s clinical profile (especially the presence of comorbid conditions), physical health, current and past medication use, treatment goals, and patient preferences for medication effects and dosing patterns. In this section, we will present an overview of the most commonly used and best-studied medications for adult ADHD. 132 Research Evidence for CBT and Medications Stimulant Medications Hundreds of published papers over the past 45 years have documented that stimulant medications are effective for children and adolescents with ADHD. A sizeable number of well-controlled studies in adults with ADHD also demonstrate that stimulants are highly effective in reducing the core symptoms of ADHD, with an overall effect size of 0.9 (highly significant; Cohen, 1992) and with response rates of 80–90% (Rostain, 2008; Santosh et al., 2011; Volkow & Swanson, 2013). In general, the stimulants are immediately effective, well tolerated, cause few side effects, and can be adjusted quite easily to suit patients’ needs. While they differ in their mechanisms of action and duration of effects, methylphenidate- and amphetamine-derived compounds work by enhancing monoamine transmission (norephinephrine [NE] and dopamine [DA]) at the synaptic level. Methylphenidate (MPH) reversibly blocks the reuptake of NE and DA into the presynaptic terminal, thereby increasing the presence of these neurotransmitters in the synapse. Amphetamine (AMP) similarly blocks reuptake of these transmitters but also increases the rate of their release into the synapse through various mechanisms. The efficacy of these agents is very similar, however, certain patients respond preferentially to one versus the other, and certain preparations (immediate release vs. extended release) are differentially tolerated. It is not yet known how to determine these variable patterns of response prior to initiating treatment other than by inquiring about the experiences of close family members. Given the absence of evidence demonstrating the superiority of one type of stimulant over the other, it is left to the discretion of the practitioner and the patient to decide which type of stimulant to initiate first. There are several products to choose from (see Appendix D) that differ primarily in terms of their delivery mechanisms and duration of action. For instance, OROS methylphenidate (Concerta® ) uses an osmotic pump mechanism to slowly release ever-increasing concentrations of MPH in a continuous fashion over 10–12 hours. The beaded long-acting preparations (e.g., ADDerall XR ® , Metadate CD ® , Ritalin LA ® ) release stimulant in two pulses: one shortly after ingestion and the other approximately 4 hours later. The prodrug lisdexamfetamine dimesylate (Vyvanse® ) is absorbed in inactive form, and the catalytic action of enzymes break the covalent bond between lysine and d-amphetamine that releases the active compound into the circulation continuously over 10–12 hours. The most common side effects seen with stimulants are appetite suppression, anorexia, gastrointestinal upset, insomnia, nervousness, and slight increases in heart rate and blood pressure. Less common but critically important adverse events include irrita- Downloaded by [New York University] at 12:14 14 August 2016 bility, mood instability, dysphoria, tics (involuntary movements), and harmful cardiovascular effects such as hypertension or cardiac arrhythmias. The onset of these symptoms may warrant discontinuation of the medication. Fortunately, recent population-based cohort studies have documented the absence of elevated serious cardiac risks from taking stimulants (Habel et al., 2011; Westover & Halm, 2012).

Nonstimulant Medications Atomoxetine (ATX) is a norepinephrine reuptake inhibitor that is FDA-approved for ADHD in adults (see Michelson et al., 2003; Reimherr et al., 2005; Simpson & Plosker, 2004). Lowering presynaptic reuptake of norepinephrine from the synapse increases the Research Evidence for CBT and Medications 133 neurotransmission of both NE and DA, leading to the positive effects reported on attention span and impulse control. ATX has an extended duration of action (longer than 12 hours) but works with gradual onset (4 to 6 weeks), such that positive effects emerge over a longer time period than with stimulants. The response rate to ATX is approximately 60% and the effect size of 0.4 is considered moderate at best. A recent clinical trial (Durell et al., 2013) documented the efficacy of ATX in young adult patients with respect to ADHD symptoms, functional status, and executive functioning and found similar response rate and effect size as in earlier studies. A 6-month study of ATX effects on executive functioning (Brown et al., 2011) found significant improvements on subscales of the BADDS, a self-report measure. Long-term follow-up studies of ATX (Adler, Spen- cer, Williams, Moore, & Michelson, 2008; Fredriksen, Halmoy, Faraone, & Haavik, 2013; Marchant et al., 2011) indicate that it remains effective in those patients who continue to take the medication with few adverse effects reported. ATX is helpful for patients who do not tolerate stimulants, who are highly anxious, and/or who express a preference for a medication that works “around the clock.” The most common side effects from atomoxetine are nausea, gastrointestinal upset, headache, sedation, fatigue, reduced sexual drive, and difficulty with urination. Mild increases in heart rate and blood pressure have also been reported, but rarely are these significant enough to require discontinuation. Alpha adrenergic agonists (i.e., guanfacine and clonidine) work by modulating nor- adrenergic activity, both at the level of the locus ceruleus (with “downstream” cortical effects) and by directly acting on receptors in the prefrontal cortex. There is evidence to suggest that attention regulation in the prefrontal cortex, and its enhancement by psychostimulants and other medications is largely mediated via alpha adrenergic receptors (for an excellent review of this subject, see Arnsten & Li, 2005). A review of the rationale and clinical utilization of alpha adrenergic agonists in the treatment of ADHD and related disorders (Sallee, Connor, & Newcorn, 2013) emphasizes the important niche that these agents occupy in the pharmacologic tool kit. They reduce ADHD symptoms directly (as monotherapy), and they enhance the actions of stimulants, as well as reducing some of their adverse effects. While immediate release preparations of guanfacine and clonidine have been available for decades, extended release guanfacine (Intuniv ® ) (Connor et al., 2010; Sikirica et al., 2013) and extended release clonidine (Kapvay ® ) (Kollins et al., 2011) have been shown to improve ADHD symptoms in children and youth on impulsivity-hyperactivity and inattention domains in registry trials. They were subsequently approved by the FDA

Downloaded by [New York University] at 12:14 14 August 2016 as monotherapy for treatment of ADHD in this age group (Intuniv® in 2009 and Kap- vay® in 2011). Unfortunately, there is very limited evidence that alpha adrenergic agonists can improve symptoms of adults with ADHD. A double-blind placebo controlled study comparing guanfacine to dextroamphetamine in adults with ADHD found that each were comparable in their clinical effects as well as their impact on neuropsychological measures (Taylor & Russo, 2001). Bupropion, a dopamine reuptake inhibitor with some norepinephrine reuptake activity, is a widely used antidepressant that has been shown to have beneficial effects on ADHD symptoms in adult patients. Its efficacy in smoking cessation provides an added value for ADHD adults who are dependent on nicotine. While it is not FDA approved for ADHD, two controlled studies (Wilens et al., 2005; Wilens, Spencer, & Biederman, 2001) 134 Research Evidence for CBT and Medications found response rates of slightly over 50% and a treatment effect size of 0.6 (moderately significant). Common side effects of bupropion include headache, dry mouth, insomnia, nausea, dizziness, irritability, and constipation. Seizures can occur in 0.4% of patients on the short-acting form of the medication but lower rates occur with the extended-release preparations. Tricyclic antidepressants, especially desipramine and nortriptyline, have been shown to be highly effective for adults with ADHD (see Wilens, Biederman, Mick, & Spencer, 1995; Wilens et al., 1996) with response rates reported in the range of 65–68%. These medications work by inhibiting the reuptake of NE, DA, and serotonin to varying degrees, which result in improved attention span and impulse control over periods of 2 to 6 weeks. A major drawback of the tricyclics is their side effects profile. Of greatest concern is the potential for cardiac arrhythmias, necessitating close EKG monitoring. Other problems include somnolence, constipation, uri- nary retention, dry mouth, and headache. Moreover, they are not FDA approved for the treatment of ADHD. Modafanil ® , a wakefulness agent approved for treatment of narcolepsy, was reported to be effective for ADHD in adults in two studies (Taylor & Russo, 2000; Turner, Clark, Dowson, Robbins, & Sahakian, 2004); however, a more recent double-blind placebo controlled study of 113 adults found that it had no advantage over placebo for ADHD symptoms (Cephalon, Inc., 2006). While Modafanil® is well tolerated and has fewer side effects compared to stimulant medications, its usefulness as monotherapy for ADHD is still questionable. At present, this agent is not FDA approved for ADHD, and it does not appear likely to receive approval in the near future. Controlled studies of combination medication treatment of adults with ADHD are surprisingly quite scarce. Weiss, Hechtman, and The Adult ADHD Research Group (2006) studied the combination of paroxetine and dextroamphetamine in 98 adults with ADHD. They found that internalizing symptoms, but not ADHD symptoms, were improved with the combination approach. Adler, Reingold, Morrill, and Wilens (2006) studied the combination of d-MPH and mirtazapine for the treatment of stimulant- associated insomnia and found that this combination was very helpful in reducing sleep problems. There are numerous case series of other combination regimens for adult ADHD with comorbid disorders (e.g. atomoxetine and stimulants, stimulants and serotonin reuptake inhibitors, stimulants and mood stabilizers), but given the current limited state of published studies, it would be premature to advance guidelines for combining medications besides suggesting that this be done with caution and careful monitoring. Downloaded by [New York University] at 12:14 14 August 2016 Pharmacotherapy Summary While there are several medication options for adults with ADHD, they have not been as widely studied as in children and adolescents with ADHD. Stimulants emerge as the most effective class of medications for reducing symptoms; however, there are secondary, nonstimulant options for patients who do not respond or cannot tolerate stimulants. Like- wise, there are tertiary medications with more limited effectiveness in the treatment of ADHD, although these agents may be useful in cases of comorbidity and/or nonresponse to other medications. Research Evidence for CBT and Medications 135 Chapter Summary The combination of pharmacotherapy and specialized psychosocial treatment, namely CBT, seems to be emerging as the foundation of treatment for the wide-ranging effects of ADHD symptoms for adult patients based on the findings from many studies. Medi- cations alone may be very beneficial for patients with relatively mild impairment and stimulants, in particular, continue to stand out as the first line of treatment to be considered. However, in complex cases involving greater functional impairment and comorbid difficulties, a comprehensive treatment plan including psychosocial treatment may be indicated. In the next chapter, we will provide case illustrations of the application of our combined treatment approach with adult patients with ADHD.

Downloaded by [New York University] at 12:14 14 August 2016 4 Clinical Case Examples

The previous chapter provided empirical support that the combination of cognitive behavioral therapy (CBT) and pharmacotherapy is an effective treatment approach for adults with Attention-Deficit/Hyperactivity Disorder (ADHD). However, practicing clinicians often do not find such evidence compelling, not because they doubt the veracity of research findings, but rather because it is difficult to translate findings from research protocols into clinically useful procedures to be used with “free-range” patients in day- to-day clinical practice. Moreover, interventions have more life to them when couched within depictions of the challenges faced by practicing clinicians in their daily work. Thus, our goal for this chapter is to provide case examples that illustrate our combined treatment model “in action.” While we cannot cover all manifestations of ADHD and patterns of comorbidity, we have selected case examples that are representative of a range of clinical issues commonly faced by clinicians treating ADHD. We are presenting new and different cases from those presented in the first edition of the book, although those past cases are still relevant. In addition to the case examples presented here, we refer interested readers to our published case reviews that may provide other clinically useful examples of CBT for adult ADHD (see Ramsay, 2011a, 2012; Ramsay & Rostain, 2005d, 2008; Rosenfield, Ramsay, & Rostain, 2008). As with all our clinical examples provided throughout this book (and other publications), all case illustrations are composed of authentic treatment experiences, though names and other potentially identifying information and details have been changed, disguised, and/or blended in order to safeguard confidentiality.

Downloaded by [New York University] at 12:14 14 August 2016 Case Example 1: Linda Linda is a 41-year-old married mother of two children who sought an evaluation for ADHD because she wanted a “do over” in her life. Both of her children had been in school all day during the previous school year, and Linda had much more discretionary time at her disposal. However, over the course of the year, despite considering several options, such as enrolling in classes or seeking work, she “never got around” to taking any action, still being at a loss to explain how she spent her time. Linda said that her experience in the past year fit a pattern that she had noticed since high school of being busy but not having a sense of completion or competency in any domain of her life. She read the book Driven to Distraction (Hallowell & Ratey, 1994) Clinical Case Examples 137 over a decade ago and noted that many of the accounts of adults with ADHD fit her own experiences, particularly those of women with ADHD. At various points in her adult life when she faced frustrations associated with poor organization and follow-through, she considered seeking an evaluation for ADHD, but “never followed through.” She ended up in tears discussing her recent frustrations with her husband, who saw it all as Linda’s “typical emotional overreaction” and as a “midlife crisis.” Nevertheless, he supported her wish to seek an assessment to help her sort things out.

Assessment Linda admitted she initially took offense to her husband’s attributing her frustration to a midlife crisis but she acknowledged that turning 40 years old, along with the fact that her children did not need as much supervision from her, had led her to reexamine her current status in life. While happy to be a mother and a full-time, stay-at-home parent, she admitted that she was greatly relieved last year when her children were in school all day. It had been overwhelming for her to manage and keep up with the various demands of marriage, raising two children, running a household, and coordinating various appointments and activities. She noticed that her friends seemed to be able to manage these same responsibilities despite having more children and holding down either part- or full-time jobs, including busy professional demands. In addition to her role as parent over the past decade, Linda was embarrassed by her little-known secret that she had never completed college. She was not sure precisely how many more credits she needed or whether they still counted toward a degree. She felt her adulthood was characterized by reacting to situations in which she found herself and simply managing well enough to get through them without following a life plan. Although she admitted “I have it pretty good,” Linda expressed frustration that she had not acted with enough intention in her life. Linda’s explicit goal was to complete her college degree in order to possibly find a job. However, she worried that too much time had elapsed and she doubted her ability to handle lectures and to organize and follow through on assignments, which had been problems for her dating back to middle school. Linda reported she had difficulty paying attention in school and was considered “nice but ditzy.” She was able to get away with completing a minimal amount of work, though this approach did not work so well for her in college. Linda was enrolled there for 5-1/2 years (due to various interruptions) but never finished, eventually leaving for a full-time job opportunity.

Downloaded by [New York University] at 12:14 14 August 2016 A structured diagnostic interview indicated that Linda endorsed the presence of a major depression that was mild in severity, which was consistent with her score on a depression inventory. She also described a chronic sense of “low self-esteem” and frustration with her problems managing affairs that her friends seemed to handle despite having busier lives. Linda reported difficulties getting started on tasks around the house and felt inadequate in her role as parent as well as spouse. She was upset by innocuous comments by her children when she was late (“Jimmy’s mom is always first in line for pick up from school.”) and at times worried that her husband might get frustrated with her and seek a divorce, which he patently denied the few times she raised her concerns. There was sufficient evidence from the various ADHD rating scales completed by Linda and those who knew her to confirm the childhood emergence of symptoms and 138 Clinical Case Examples their persistence into adulthood. The benefit of multiple raters was that, although there were many common observations, there was a degree of nonoverlapping symptoms related to her functioning. That is, her mother provided observations of Linda in childhood based on behavior at home and comments from teachers, while her sister was able to recall Linda at school and in situations with peers. Similarly, Linda’s husband and sister had different interactions with and observations of her in adulthood. Evidence from self- and other-report versions of the Barkley Deficits in Executive Functioning Scale (BDEFS; Barkley, 2011b) indicated that she had moderate deficits in each domain of executive functioning, including emotional regulation, which was consistent with her emotional “overreactions.” Linda’s performance on neuropsychological screening measures indicated some evidence of executive dysfunction, mostly on measures of auditory working memory, cognitive flexibility, and nonverbal problem solving. These findings were consistent with her accounts of having problems organizing and remembering information in day-to-day tasks. Her performance on a computerized continuous performance task indicated poor attention vigilance. Linda said that she was not identified with ADHD in childhood or adolescence, but discussions with her mother and her sister revealed that there were past concerns about her struggles. Her mother said that teachers commented that she was nice but seemed to “daydream” in class and did not perform “to her potential.” Linda’s sister remembered that Linda seemed to spend a lot of time working on school work, though she would not be focused, whereas her sister got more done in less time. Linda recalled she got through middle and high school with average grades, sometimes struggling in math but was never in danger of failing. Linda had significant struggles in college. As was mentioned earlier, she was enrolled in classes over 5-1/2 years but did not complete her degree because she often had to drop courses to avoid failing grades or because she exceeded the permitted number of absences from class. She took a leave of absence the first semester of her sophomore year and lived at home because of problems adjusting to her first year, including excessive alcohol and marijuana use. She established her abstinence while living at home and maintained social drinking after her return to school, though she continued to encounter academic problems when she resumed classes. The summer before what could have been her final semester in college she found a job working as an administrative assistant in a company. At the end of the summer, she was offered a full-time job with benefits. She intended to return to school after earning some money “but never got around to it.” She said that her job performance was incon-

Downloaded by [New York University] at 12:14 14 August 2016 sistent but her boss had become Linda’s friend and “let (her) slide.” However, after this boss left for a new job, Linda’s new boss rated her work performance as substandard, and Linda eventually quit before she could be fired. She worked a variety of different jobs over the next several years, sometimes moving home to live with her parents when she was unemployed. As Linda approached turning 30 years old, she realized that she was “still trying to get (her) life together.” Around this time she started dating her husband-to-be. Theirs was a stable, monogamous dating relationship. Linda said that she was not sure if “he was the one,” but she got pregnant unexpectedly, and they decided to get married. They have maintained a stable partnership, though the circumstances of their marriage and her low self-esteem contribute to her insecurities about his feelings for her. Clinical Case Examples 139 Throughout her evaluation, Linda wondered if she was making too much of the extent of her difficulties, stating “maybe it is not so bad” and that she simply needed to “toughen up” and “just do it.” However, during the feedback session for the evaluation during which the various clinical data and the recurring patterns and difficulties across time and situations were reviewed together, Linda began to connect these experiences and recognize the impact of ADHD on her functioning. Even more specifically, the evidence supported that Linda’s presentation was consistent with the combined type of ADHD, exhibiting features of both inattention and behavioral disinhibition. Linda’s eyes filled with tears as the evaluator concluded that her case was consistent with and fulfilled criteria for ADHD. She said that they were tears of relief because, in fact, her difficulties had a valid explanation and the diagnosis helped her to make sense out of the ongoing disconnect between her intentions and her follow-through, or lack thereof. Linda was deemed a good candidate for combined CBT and medication treatment. When reviewing her options, she was reticent to start medications. She had researched adult ADHD and understood that medications were the accepted first line of treatment. However, she said that she rarely took even over-the-counter medications and was not ready to commit to taking a prescribed medication for ADHD. The evaluator provided some general information about the common medications used to treat adult ADHD and their common side effects, as well as their therapeutic effects and answered some other of Linda’s questions and concerns. Linda decided to start CBT and to defer the medication option for the time being.

Course of Treatment

CBT The first session of CBT was spent clarifying Linda’s treatment goals based on specific examples of difficulties she faced in her day-to-day life. In addition to serving as “measure- able behavioral objectives,” these targets also help adults with ADHD to gain an understanding of how ADHD and its associated executive dysfunction and motivational deficits influence their functioning, representing the psycho-education component of CBT. Linda cited several areas of difficulty, expressing a sense of being overwhelmed at not knowing where to start to make changes. She wondered if maybe hers was a hopeless case, as she could not envision ever being able to make such sweeping changes in her life.

Downloaded by [New York University] at 12:14 14 August 2016 Although usually identifying specific examples of coping difficulties before examining cognitive processes, the therapist, who had conducted her evaluation, had heard evidence of Linda’s sense of inadequacy throughout the assessment. Hence, he jumped into the CBT strategy of the “downward arrow” (Burns, 1980) to elicit underlying attitudes that would likely play a role in treatment.

Therapist (T): So, you’re feeling overwhelmed by everything that you want to change and all the responsibilities you have in your family, not to mention wanting to fi nish college. A fi rst step we can take is to focus on using a Daily To-Do List and Daily Planner to organize your tasks into specifi c and manageable action plans. It is the same thing we are doing now—we are looking to “start small” 140 Clinical Case Examples by focusing on a reasonable set of things that you can do in a day to make the changes you want. Does that make sense? Linda (L): Yes. I’m glad you said that because I get overwhelmed when I think about all that I have to do. It seems impossible that I will ever be able to do everything. T: I wanted to ask you about that. You mentioned earlier that you felt hopeless when we were discussing some of your goals. Although the ultimate goal for our work is to have you be able to do things differently, our attitudes, how we think about what we want to do affects follow-through. What thoughts were going through your mind a few moments ago when we were started to turn you larger goals into specifi c tasks? L: I felt overwhelmed and anxious. T: Okay, those are the feelings or emotions you had. What thoughts did you have or, said differently, what did our discussion of your goals mean to you at that moment? L: I was thinking that I should not need a special evaluation and treatment to make myself do things I should be able to do on my own. I think of all the things I should do but never make progress on any one of them. To be honest, I worry that I probably won’t be able to follow through on this (CBT) and then I’ll still be stuck. T: As a thought exercise, let’s take this a step further. Let us assume for the purposes of this exercise that these concerns are true—that you, Linda, require extra support to do things that others do on their own and that even this specialty adult ADHD program ends up not helping—if that happens, what would that say about you? L: That I cannot even get myself to follow through with something that has helped other people in my situation. Even with all the benefi ts I’ve had in life, I still cannot do what I need to do for myself or my family. T : Again, based on what you just said, assuming for the time being that these statements are true, what does that say about you? L: I’m really a screw-up compared with everyone else I know. I have all the advantages and still cannot follow through on anything. My family can’t rely on me and I must really be incapable to do these things.

The therapist pointed out how quickly even a discussion of Linda’s goals triggered uncomfortable, though familiar, negative emotions associated with her past frustrations,

Downloaded by [New York University] at 12:14 14 August 2016 what had been dubbed her “typical” overreaction. These triggers activated what the therapist hypothesized were schema related to inadequacy and self-mistrust. More specifically, part of the work of developing coping strategies would involve monitoring how Linda’s reactions could “hijack” her coping efforts. In order to resume a focus on specific treatment goals, the therapist asked Linda the question, “How do you decide how you ‘spend yourself’ each day?” to have her consider how she budgets her time and energy throughout a day. She cited several examples of household tasks or steps she could take toward her goals, though she said that these were the same items she had not done over the previous year. The point was made that having a daily schedule helps with time management, which also includes “effort” and “energy” management. It was agreed that her first homework task would be to work on a Clinical Case Examples 141 Comprehensive To-Do List to sketch out the various obligations and tasks she faced over the next few weeks. She also agreed to use a Daily Planner to track how she spent her time without necessarily changing her schedule. During the next meeting, Linda said that the exercise of thinking through her plans and tracking her actual activities showed her how inefficient her days were and how much she procrastinated on even mundane tasks. She was asked for a recent example of procrastination. Linda had several e-mails from friends for which her response was long overdue. Her therapist guided her through a reverse engineering of her procrastination script, elucidat- ing a common pattern of sitting down at the computer with the intention of responding to them but getting distracted by other websites, etc. She agreed that it would be a positive accomplishment to respond to at least one of these e-mails before the next session. Linda and the therapist defined a specific time that she could devote to responding to a specific delinquent e-mail, making it an appointment that she could schedule in her Daily Planner. The therapist asked Linda to describe her thoughts about sending this e-mail response. She said that she felt uncomfortable based on the assumption that the friend would be angry with her for not responding earlier. Linda also wrestled with an excuse for why she had not responded earlier, though she was convinced that friend would “see right through” any reason given. These sorts of anticipations resulted in her typical escape behavior—“I’ll deal with this later.” The therapist pointed out that, based on these assumptions, it made sense that Linda responded as she did because, in her eyes, there was no viable outcome other than an angry friend. The first step was to simplify the behaviors that Linda had to execute to complete the task. The “behavioral script” for the task was find the e-mail, read what the friend wrote, and provide the briefest response appropriate, even if it might be as basic as “Glad to hear things are well. Hope to catch up more later on” and without providing any excuse for its tardiness. Linda’s personal experiences were used to explore possible alternative outcomes to sending the tardy message (e.g., “Are you angry when someone responds to a message from you after a long while, or are you happy to read what they wrote? How common do you think it is that people fall behind on responding to e-mails? Is it more likely that a person assumes ‘Linda’s busy’ or that ‘Linda does not care’?”). It was acknowledged that all Linda can control is her own behavior; she cannot be 100% sure of the recipient’s reaction, although she was operating (or procrastinating) based on the anticipation of rejection. Instead, Linda was encouraged to focus on the value she places on the task in order to complete the steps to execute it.

Downloaded by [New York University] at 12:14 14 August 2016 It was anticipated that Linda might feel the impulse to escape the task when writing the message or preparing to hit the “send” button. This reaction was normalized but was reframed as an opportunity for acceptance and follow-through (“I can feel some discomfort but still hit the ‘send’ button to accomplish the task.”). She also reminded herself of her reasons for sending the message. At her next session, Linda happily reported that she sent the e-mail and has a positive feeling of accomplishment from doing so. She was surprised by the level of relief she had from being able to “cross it off (her) To-Do List.” Her friend responded the next day with a very enthusiastic reply, making no mention of Linda’s message being “tardy.” Linda said that the experience of tackling the overdue e-mail helped her to respond to other e-mails, which left her feeling productive. 142 Clinical Case Examples Linda’s case is in line with our clinical observation that the coping strategies for adult ADHD provide patients with “scaffolding” or templates, first, for being able to “see” the negative effects of ADHD and, second, to have alternative approaches for adaptive coping. When patients implement these coping skills, they have the visceral experience of positive reinforcement that comes from real world outcomes. Linda found it useful to use a Daily Planner to schedule her time and activities, including setting up times to deal with e-mail. She recognized that she actually had much more free time than she originally thought because she had previously spent so much time on low priority activities. Time was spent in session using her planner to illustrate the process of prepopulating it with various obligations (i.e., morning routine, drop-off and pick-up of children from school, etc.) and identifying various activities and tasks to perform during discretionary times, including the notion of scheduling “downtime.” A session was devoted to helping Linda proactively set up a daily plan. She was encouraged to spend 10 minutes the night before, using her Daily Planner and filling in all the existing obligations, including her morning routine, meals, taxiing children around, etc. Her priority tasks that fell outside these typical obligations were listed out on her Daily To-Do List and also scheduled for specific open time slots in her planner. Linda was encouraged to err on the side of underscheduling, allowing sufficient time to complete tasks, commute between locations, etc. It is important to keep the daily plan realistic rather than falling into a tendency to “do everything all at once” in order to reduce the tendency to become overwhelmed, which was a central issue for Linda. Another skill that emerged as being important for her was assertiveness and Linda’s ability to say no. In addition to Linda being able to set realistic plans for herself, we discussed how she selects the types of tasks she takes on or agrees to. She would become overcommitted by agreeing to requests from others, either based on her initial enthusiasm or out of a sense of duty (“How can I say no to being the preschool parent coordinator—I’m the only parent who does not have a job.”). Linda found the tactic of responding to requests by “buying time” to be helpful, that is, “Let me think about that and get back to you.” Linda described what is a common experience among adults with ADHD: trying to please others by taking on tasks based on the perception of having built up interpersonal debt (e.g., “How can I say no to designing and sending out announcements to parents about the school carnival when the teacher has stayed late with my children when I have been late for pick-up?”) rather than viewing each request on its own merits and judging how it fits into her schedule.

Downloaded by [New York University] at 12:14 14 August 2016 Another principle of assertiveness is proactive negotiation, such as responding to a request with a counter-proposal (e.g., “I cannot commit to working on the invitations, but I am available to volunteer on the day of the carnival.”). After several sessions focused on planning and implementing daily activities, Linda brought up an important, longer-range goal: completing her college degree. This goal was discussed and broken down into some initial component steps that could be carried out in the next week or so. That is, Linda’s return-to-school goal was broken down into action steps. An initial barrier was the fact that Linda had been out of school for so long that she did not know about the process for resuming classes toward a degree or if her existing credits were even still valid. Thus, a first step was defined as contacting her college for accurate Clinical Case Examples 143 information. This seemingly simple step was fraught with anticipatory thoughts about how she might be viewed (e.g., “I’m going to look silly trying to finish a degree after so long.”) or about what she might find out (e.g., “I’ll be 50 years old before I am done if they do not accept my old credits.”). Cognitive modification was used to address these “jumping to conclusion” thoughts, and a behavioral script of what she needed to do to gather information was developed. This entailed contacting a college representative, explaining her situation, and asking for assistance. Linda completed the phone call and learned that she needed to complete three courses to fulfill her degree requirements. One of them was to be offered during an upcoming summer session at a local satellite campus of the college. After working through the pros and cons of this option and discussing it with her husband, she decided to enroll in the course. Linda reached this point in CBT despite declining medication treatment, making good progress, nonetheless. However, considering her history of attention and concentration difficulties in school and when reading required texts, Linda agreed to a medication consultation about 2 months before the class started. CBT sessions focused on using the principles of time management, planning, and dealing with procrastination in order to prepare for her class.

Pharmacotherapy Linda was prescribed OROS methylphenidate (Concerta® ) 36 mg daily and immediately noticed improvements in her ability to sustain concentration on tasks as well as to manage her emotions. She said that she was able to enjoy pleasure reading more and was better able to retain information she read or heard. After several weeks at this dose, she noted a reduction in efficacy and reported this immediately to the psychiatrist who advised her to increase the dose to 54 mg. This change was accompanied with a sustained reduction in her ADHD symptoms that was maintained throughout the course of her CBT treatment. Linda completed and passed the class. It was a challenge but not as difficult as she anticipated to get back into “student mode.” Linda used coping skills of “lowering the bar” when she started to feel stressed, focusing on the specific assignment at hand. She also broke down tasks into discrete steps and made appointments for when and where to work on these steps, such as going to the library after class. Linda also found some suggestions for students with ADHD helpful, such as an approach for handling reading assignments (i.e., SQ4R). Toward the end of the summer session, she found herself

Downloaded by [New York University] at 12:14 14 August 2016 engaging in more procrastination, growing anxious about her ability to keep up with final assignments and simply “hitting the wall,” wanting the class to be over. However, she was able to study enough to earn a solid grade, earn credits toward her degree, and to follow through on an important, personally relevant challenge that she had previously thought she was incapable of completing. Linda made significant progress over the first 9 months of CBT, with medications added in the fourth month. Linda’s represented a relatively straightforward case of adult ADHD from a diagnostic standpoint. Her sense of inadequacy and self-mistrust was a complicating factor, insofar as they interfered with her emotional endurance for handling frustrations. However, the fact that she was able to implement an assortment of coping tactics to handle situations she would have typically avoided provided her with her 144 Clinical Case Examples insights about her resilience and about her sense of self. Linda seemed more confident in her ability to set out and follow through on plans and to advocate for her own well- being. She may not have been able to achieve a “do over” of her life, but Linda certainly was better able to “do” her life in a manner in which her intentions and actions were more closely aligned.

Case Example 2: Ian Ian is a 23-year-old college student who describes his status in college as “somewhere in my junior year,” though most of his friends were graduated over a year ago. His parents arranged for and brought him to the assessment, which was scheduled a few weeks prior to the start of the fall semester of what was to be Ian’s sixth year of college. His parents had been urging him to get an evaluation for ADHD since he faced problems during his freshman year that culminated in an academic leave of absence after falling hopelessly behind in his work. Ian resisted this suggestion, promising to work harder, use campus support services, and other concessions, each of which he did for a brief while, though none were consistently maintained. Having seen many of his friends move on, Ian realized that he was on track to be graduated after his 25th birthday. Facing the recognition that he would be “old” by the time he finished college, he agreed to accept help. Ian admitted that he had not yet completed a paper from an incomplete he took the previous semester and now faced a new semester with this looming task and the prospect of taking more upper-level courses.

Assessment Ian’s parents accompanied him to the evaluation and he asked that they participate in order to provide their observations. His parents said that it had been suggested at times throughout high school that he might have ADHD but his academic performance was “solid, but not great” and he was graduated on time. However, Ian noted that he seemed to have to work harder than his peers to complete the same amount of work, even though he did not characterize himself as a hard worker. He got through school by completing the minimum requirements and, frankly, often got away without submitting homework. Ian’s parents had closely monitored his assignments throughout primary and secondary school. They sat with him to ensure he completed homework during middle school and checked his work as best they could when he reached high school. Ian’s parents grew

Downloaded by [New York University] at 12:14 14 August 2016 concerned with the amount of time he spent gaming and immersed in technology during the latter half of high school. Ian admitted that he got into the habit of lying to his parents about his progress on assignments in order to “buy time.” He often put off assignments until the last minute due to gaming, sometimes missing a deadline and pleading for an extension, unbeknownst to his parents. From the outset, Ian struggled at college with handling his newfound independence without the structure provided by his parents. He missed several morning classes due to oversleeping after staying up late with friends or gaming online. He was able to keep up during the early weeks of the semester because the content of some courses was familiar to him from high school. However, Ian was disappointed by his initial grades on exams and papers, finding out that tests included information from textbooks not covered in class. Clinical Case Examples 145 Ian ended up on academic probation the second semester of his first year due to his low grades. He ended up taking a leave of absence the next year due to an anxiety disorder diagnosed at the student health center. During his leave of absence, he worked a part time job, took community college classes, and had psychotherapy for anxiety. Though still gaming on the computer and having poor sleep habits, he performed better in community college due to the “scaffolding” at home and the fact his parents again monitored his school work. Ian returned to his college that fall and passed his classes, taking the minimal full- time load. He had standing check-in meetings with his advisor who sent Ian to the campus learning center for added academic support. Ian’s class attendance was better, though still inconsistent, and he relied on extensions for a few assignments. He achieved (barely) the requisite grade point average to be taken off academic probation. Semesters leading up to the one that prompted the evaluation were described by Ian’s father as a “grind.” After getting off of academic probation, Ian no longer kept in touch with his advisor or learning center counselor. He faced an upsurge in problems after declaring his major and taking upper-level business and economics courses. Ian said he chose this major for its perceived earning potential rather than his interest in the topic. He said that he realized the need to focus on school in order to finish college and move ahead with his life. However, he said that he was unable to manage the amount and difficulty of work, requiring inordinate time to keep up. The fact that he had to drop courses and could barely pass others despite his efforts led him to agree to the assessment. Structured diagnostic interview indicated that Ian endorsed many symptoms of anxiety. Though falling below the diagnostic threshold of number and severity required for Gener- alized Anxiety Disorder, Anxiety Disorder, Not Otherwise Specified was indicated. He also reported features of current depressed mood that fulfilled diagnostic criteria for an episode of Major Depression consistent with his moderate score on a depression inventory. Ian also admitted to generally low levels of alcohol and marijuana use, the latter often used to help him fall asleep. While these behaviors did not reach the level of abuse, his marijuana use seemed to be tied in with anxiety and poor sleep habits, which magnified (and were magnified by) his ADHD-related difficulties. Said differently, the pattern of alcohol and marijuana use was a concern more so for its effect on procrastination and poor self-regulation than for the absolute amounts used. Of even greater clinical concern was his excessive technology use. Ian and his parents completed several self-report ADHD symptom questionnaires for both childhood and current functioning and for current executive functioning. There

Downloaded by [New York University] at 12:14 14 August 2016 was general agreement between Ian’s and his parents’ ratings to indicate that he had exhibited clinically significant symptoms of both hyperactivity/impulsivity and inattention during childhood that fulfilled diagnostic criteria for childhood ADHD. His mother presented some old school report cards containing teacher comments about his behaviors and performance. Although he was never in danger of failing any class, comments on report cards and other student evaluations indicated the presence of disorganization and poor follow-through, which adversely affected his grades. Regarding current symptoms, Ian self-endorsed enough symptoms of each subtype to warrant a diagnosis of ADHD, combined type, with his parents’ ratings of the same symptoms indicating even greater severity. The results on the standardized, self-report adult ADHD questionnaires provided further confirmation of his current symptoms 146 Clinical Case Examples and difficulties. This trend also occurred in the rating of current executive function difficulties, with both self and parent ratings indicating moderate to severe elevations on all five executive functions, and an index of risk for ADHD. Regarding ADHD, Ian’s was a straightforward diagnostic case, although we could see how it could have been missed in light of coexisting mood, anxiety, and substance/ technology overuse. His case fell toward the upper moderate range of severity of symptoms, though it was not until the increased demands of college served as a “breaking point” at which unmistakable impairments were revealed. Ian’s performance on various neuropsychological screening measures was mixed. His scores on subscales on an intelligence test fell in the average to high average range, except for speed of processing, which fell in the below average range. Scores on tests of auditory working memory for words and cognitive flexibility fell in the below average range, and performance on a computerized continuous performance task indicated high number of errors (both omission and commission) and poor attention vigilance. Ian said that these findings were consistent with his experience of taking longer to understand and make sense of information and with his “low-attention endurance.” Ian described the frustrating sense that he should have been able to keep up with the work and at least pass classes in college but he eventually fell behind, not taking action until the situation reached a crisis point. He reacted by either spending inordinate amounts of time catching up on work or becoming overwhelmed by what he had to do and giving up. He reported, “I know what I need to do but have a hard time doing it.” We liken the adjustment to college life for students with ADHD to the tectonic plate shifts that create earthquakes. The earth is comprised of a series of plates that push up against each other. As long as the plates are in line and stable, the ground is solid. How- ever, when the plates shift out of alignment, the ground on the surface shifts, and there is an earthquake. Moving away to college results in a complete overhaul of students’ lives, requiring them to adjust to a new geographic setting, living situation, social network, and a more challenging set of academic demands. College also requires increased personal responsibility for self-care and self-management. These changes are particularly difficult for young adults with ADHD to manage, particularly if ADHD has gone undiagnosed. During the evaluation feedback session, the results from the various interviews, inventories, and tests were reviewed, as were the diagnostic impressions. Ian was ambivalent about the diagnosis of ADHD, but when it was defined using an executive dysfunction model (e.g., “difficulties organizing behavior across time . . .”), he seemed much

Downloaded by [New York University] at 12:14 14 August 2016 more receptive to it; in fact, he said that this explanation was consistent with his recurring problems throughout college. The option of pursuing a comprehensive psycho- educational evaluation to see if he would qualify for academic accommodations was discussed but the family decided to defer this option for the coming semester. He agreed to resume academic support through the campus learning center. Ian and his parents agreed that it made sense for him to start CBT and medications simultaneously in order to have full treatment support. Considering that he would have to make a special trip to the clinic office from the college where he was enrolled, he was encouraged to obtain a planner to manage his schedule and appointments. It was also suggested that he bring the planner to his first CBT session in order to use it to make plans for the upcoming semester. Clinical Case Examples 147 Course of Treatment

Pharmacotherapy At the initial visit with the psychiatrist, Ian professed an aversion toward taking stimulant medications. He admitted to having tried a few doses of Adderall at college which he had obtained from a friend in his dorm. While it helped him to stay up and get his work done, he also found that it made him nervous and jittery. Given his level of depressed mood and his preference to avoid taking stimulants, the treating psychiatrist recommended a trial of extended release bupropion, beginning with 150 mg daily. Ian returned in 2 weeks and reported some improvement in his mood and concentration, but he remained in the symptomatic range for both target symptoms. The bupropion dose was increased to 300 mg daily, and within another week, Ian noticed some changes in his ability to concentrate. More importantly, he reported being more motivated to take on his college work, and more hopeful about the future. It was decided to continue on this dose of medication for another month at which point he would return for a follow-up visit. At that time, his mood was in the normal range and his ADHD symptoms were markedly reduced from baseline. He continued on this regimen for the remainder of the semester and into the following school term.

CBT Ian arrived on time for his first CBT session but without a planner. He was apologetic and anxiously promised to make a special trip to get one. The therapist thanked Ian for being up front about the situation and noted that the planner issue would be a useful one to put on the therapeutic agenda to discuss. The therapist also conjectured that Ian experienced similar sorts of frustrations with other tasks that he intended to do. Ian nodded and said that he worried that he had “failed” his first therapeutic task. The therapist said that the situation with the planner “makes perfect sense” in light of an understanding of ADHD. The therapist asked Ian about how he had planned to obtain the planner after the feedback session as a means to reverse engineer “what happened.” Ian said that he “meant to do it,” remembering the errand from time-to-time, but not doing it despite ample opportunities. Looking ahead, he claimed, “I just have to remember and make myself do it.” The therapist responded with qualified agreement, adding that the purpose of CBT for adult ADHD is to help Ian to develop better ways for getting himself to “do it.” In addition to developing an action plan for obtaining the planner and thereby intro-

Downloaded by [New York University] at 12:14 14 August 2016 ducing the notion of a Daily To-Do List, a 1-week activity chart was used as a temporary proxy for the planner. Ian and the therapist outlined the various tasks he had to perform to get ready for the upcoming semester as well as different social and recreational plans he had, including time spent “hanging out” with friends. Filling in the activity chart with these items helped illustrate the benefits of externalizing time and tasks and to model how to use a planner to organize time and effort. Obtaining the planner was one of the tasks entered in the chart. Considering his coexisting mood and anxiety issues, the role of his emotions in terms of motivation for tasks was also discussed in the context of getting things done. That is, it was pointed out that it was unlikely that “buying a planner” was the type of task that would leap to Ian’s mind as something fun to do, unlike gaming or spending time with 148 Clinical Case Examples friends. Hence, similar to going to class, getting started on assignments, or other “have to” tasks in life, motivation must be manufactured by other means. In particular, even the notion of putting “buy planner” on a Daily To-Do List was reviewed to anticipate barriers to follow-through. Ian admitted that seeing all he wants to and has to do in the 2 weeks before the start of the semester made him feel a degree of stress. He was capable of each task but his automatic thought was “I will be spending the rest of my break running errands and I won’t have enough time to relax before the semester.” It made sense, then, that he would view it as stressful to obtain a planner. Ian agreed to the experiment of obtaining the planner. In addition to his commitment to an obligation, which was one of his goals for the upcoming semester, he was also asked to take note of his experience of obtaining the planner and how this action affected his energy and ability to enjoy himself afterwards. It was normalized that he would not “be in the mood” to get a planner, but that it could be set up as a collection of specific steps that he could perform at a scheduled time. The implementation strategy was phrased as, “If I am tempted to put off getting the planner, then I will remind myself that it will not take long and it can feel good to get things done.” There were some additional pragmatic barriers to Ian obtaining a planner, including coordinating the use of the car with his parents, deciding on the “right” planner to get, etc. The therapist summarized back the various issues that could interfere with Ian obtaining the planner. The issues reflected a combination of disorganization, difficulties with problem solving (i.e., developing a sequence of specific steps), and the aforementioned cognitions and emotions about tasks. Hence, in addition to the implementation strategy, Ian and the therapist collaboratively developed a step-by-step plan or recipe for obtaining a planner. Finally, some specific automatic thoughts about finding a “right” planner were highlighted for modification (i.e., “Is there a way to choose a ‘wrong’ planner? If you later find that a different planner will work better, you can simply get a different one.”). Ian left the first session with the plan for obtaining a Daily Planner as well as the suggestion to monitor how he spends his time by documenting it in the planner. It was also suggested that he populate his planner with those commitments that were already scheduled, that is, classes, scheduled advisor meeting, intramural sports schedule, etc. The purpose of this task is to help externalize time and activities in order to improve planning and time organization. Ian arrived at the next session with his planner, and he had done a good job tracking his activities and inserting his known classes and commitments for the upcoming semester. He also acknowledged that it was not as bad as he anticipated it would be to run the

Downloaded by [New York University] at 12:14 14 August 2016 errand to get the planner. He felt a sense of accomplishment, and he still had plenty of time to do other things. When asked about his observations of how he spent his time over the week, Ian said while he knew he spent a lot of time on the computer, tablet, and other electronic devices, it was shocking to see how much time once he tracked it. He also commented on how irregular his sleep habits were. Using this initial information, Ian and his therapist discussed his schedule for the upcoming semester in broad terms by referring to the planner. In particular, known obligations, such as time in class and other scheduled commitments were reserved in the planner. Then, the discussion turned to gaining a sense of when would be good times for Ian to spend studying, socializing, and following through on other interests (or at least times he recognized he would likely not focus on studies). Clinical Case Examples 149 The take home point for college students is that “there is time enough for everything,” although they will have to make concessions regarding when they do things. More specifically, there is ample time for socializing and other recreation activities, but there will be certain, specific times when academics are the priority. Ian and his therapist developed an initial “game plan” for the first week of the semester in terms of getting off to a good start by reserving time for studying, using the principle of defining “studying” in terms of specific, time-limited tasks in order to increase activation (e.g., “I will read at least 10 pages” or “I will work on the problem set for at least 20 minutes.”). Times were also reserved for personal interests (e.g., going to gym, watching college football games on television). Ian reported very good progress through most of his first semester. He was diligent about attending his CBT sessions as well as his concurrent pharmacotherapy appointments. Ian said that he was keeping up with his work more effectively than he had in the past. In particular, he was able to complete a paper for a class on time without waiting until the last minute. He said that he found the exercise of breaking down the specific steps and defining specific “writing” tasks to help him get reengaged in the paper very helpful, that is, “resume working on the paper by reading what you have written already.” Cognitive and emotional regulation skills were used to address issues related to writing, namely Ian’s perfectionism that actually served as a compensatory strategy for his sense of inadequacy (“I am not a good writer. This is not good enough.”). The therapist and Ian identified that these concerns heightened his anxiety and put him at risk for procrastination. They developed cognitive reframes of the task, such as his objective for the paper is to complete it and submit it by the deadline rather than trying to earn a certain grade. Ian was also encouraged to address his anxiety by decatastrophizing the situation, thinking through the likelihood that he would actually get a failing grade (which was associated with the feared fantasy of never finishing college, which would eventually lead to being homeless, etc.). When discussing these issues aloud and identifying distortions, Ian was able to establish a better perspective. Specific writing tactics were also helpful to Ian. He said that he typically did not spend time on outlines, instead preferring to work it out on the computer. However, this was reframed as avoidance of thinking about the paper. Instead, the outline was reframed as a specific block of time spent thinking about the paper. Ian liked the notion of the ideas for a paper being similar to a Power Point presentation and, in fact, the assignment involved doing a presentation of the paper in class after it was handed in. When it came to writing the paper, Ian was encouraged to draw on the ideas from his outline and simply get them into narrative form during the initial drafts rather than editing himself as

Downloaded by [New York University] at 12:14 14 August 2016 he wrote. When it came time to clarify the expression of an idea, he found it helpful to express it aloud as if he was explaining it to someone else as a means to get “unstuck.” By the end, Ian was better able to tolerate the variability in production (e.g., “Some days I will write four pages, some days four sentences.”), but focus on his on-task behavior (e.g., “I will feel better about those four sentences than if I do not do anything.”). Ian continued to attend his CBT sessions during the semester. Sessions were used to track his progress, engage in problem management regarding various issues that arose, and identifying and dealing with minor slipups, such as missing a class due to oversleeping, etc. He reported feeling less anxious about school and had increased confidence about his ability to “do things.” In addition to problem management, the therapist reinforced for Ian the things that he was doing well and framed them as skills that he could 150 Clinical Case Examples use, even if and when there were slipups. The therapist noted that it’s not whether someone procrastinates or slips into a bad habit, but when and, more importantly how the person deals with it. As the end of the semester approached, Ian’s parents accompanied him to a CBT session, reporting that Ian had fallen woefully behind in a major project for one of his classes. He had told his parents and the therapist that he had been working on it, but it was a cover up of the fact he had barely done any work on it. Ian’s parents were aware of the project in question and when they pressed him to see the project in order to read it and give him feedback (which they had done with his permission in the past), he finally admitted that he had stopped working on it. Ian also admitted that he stopped going to the class in question and he could fail the class at the professor’s discretion based on the college’s attendance policy. During the family meeting, his parents were understandably upset that they had been lied to, particularly because they had allowed themselves to be more hopeful about the semester based on the reports Ian had given them. Ian was contrite but also grew uncomfortable as he felt his parents were “piling on,” repeating their frustrations and concerns. The therapist intervened by summarizing the feelings and frustrations of all involved as well as the fact that CBT (and any psychosocial treatment) is predicated on accurate information. Acknowledging that it was likely little comfort to them, Ian’s parents were advised that the issue of a college student with ADHD lying about a tardy project in order to “buy time” to catch up but eventually being “caught” is not an unfamiliar one, albeit far from ideal. With Ian’s permission, he and the therapist engaged in a review of events from the point at which Ian started to fall behind in the project, his responses to this fact (including lying), and efforts to manage up to the point he stopped going to class. There were several factors that led Ian to fall behind in the project, but a central issue was that he was confused about an aspect of the project requirements, namely he was worried that background sources he had been using for his project did not precisely fulfill the professor’s stated parameters for acceptable sources of information. Ian’s confusion and anxiety grew because his chosen topic was already one that did not neatly map onto the project requirements. Hence, Ian was worried that all of his time and effort might be for naught. Ian avoided the issue with the positive thought, “I’ll figure it out, somehow,” but this only provided brief relief from the realization that he was falling far behind on the project. He stopped working on the project altogether, being stuck between worry that his efforts were pointless and would result in a failing grade and worry about reaching out

Downloaded by [New York University] at 12:14 14 August 2016 to his professor, anticipating the worst-case scenario of getting confirmation that his topic was unacceptable. This sequence of events activated Ian’s old pattern of becoming overwhelmed, frozen, and eventually isolating and giving up out of shame. Ian’s parents were befuddled as to how he could not reach out to them, the professor, or the therapist for help. Ian said that he has never sought out teachers for help, even dating back to high school. He worried that the professor would tell him that he had to start over with a new topic, which would require a lot of work on his part. Moreover, after waiting so long to raise the issue, Ian anticipated a negative reaction, such as the professor criticizing and blaming him for waiting so long, and saying that there was nothing that could be done about the project or his absences, resulting in an obviously self-defeating cycle for which there was no easy way out. Clinical Case Examples 151 It was agreed that Ian and the therapist would develop a coping plan that Ian would share with his parents. While meeting to set up the coping plan, the therapist asked Ian if there were any of other factors relevant to his situation that Ian did not mention in the presence of his parents, such as substance use or other difficulties. Ian replied there were no such factors, he simply procrastinated. The therapist next explored if Ian had any concerns about the therapist or treatment that made him reticent to raise his school problems during an earlier session. Ian said that he thought he could handle the situation on his own, and in part because he was embarrassed after having started off the semester by doing so well. After falling so far behind and missing classes, he felt ashamed to admit the issue to anyone, even his friends. The therapist empathized that it must have been stressful and difficult for Ian to face the consequences of a situation that spiraled out of his control. Despite the current predicament, however, the therapist expressed the genuine sense that it represented yet another opportunity for Ian to face and manage circumstances he would typically avoid. Ian said that he was doubtful about the outcome but observed that it felt better having his situation now out in the open. Ian and the therapist developed a step-by-step action plan that started with Ian sending an e-mail to the professor, explaining the situation and requesting a meeting to review his options. Cognitive interventions and emotional management interventions were used to address his potential avoidance of this task, including dealing with his mind reading (“I know he will just fail me. He must think I’m a loser student.”), exploring adaptive thoughts (“It is probably not first time this professor has encountered a student who has been in this sort of situation. I cannot do his thinking for him and can only focus on my actions.”), and reframing his emotions (“Can you invest short-term discomfort involved with sending the e-mail and having a meeting with the professor in order to resolve this situation, one way or another? Remember that you felt better after telling your parents about this.”). Ian and the therapist wrote out the behavioral recipe and he agreed to share it with his parents. Ian sent e-mail updates to the therapist in the week between sessions, and he made the decision to copy his parents in order to be transparent and to let them know he had followed through. His professor responded and arranged a face-to-face meeting with Ian, which he recounted at his next CBT session. During the meeting Ian explained his situation, noting that he has ADHD and that he is working on improving his follow- through on tasks. The professor was receptive to Ian’s stepping forward to handle the situation, sharing that he, in fact, has a college-aged nephew with ADHD who faced similar challenges keeping up with work. The professor said that he assumed that Ian dropped the course when he stopped attending, which he said was perplexing because he

Downloaded by [New York University] at 12:14 14 August 2016 considered Ian to be a good student. The professor understood the confusion about the assignment in light of Ian’s topic. It turned out that Ian’s sources were acceptable as they were within the “spirit” of the assignment requirements. The professor offered Ian a deadline extension and made himself available to meet with Ian to discuss the project. The professor agreed to waive the attendance policy provided that Ian attended the remaining classes in the semester. Ian and the therapist reviewed the pros and cons of various options for the project. One option raised by Ian was simply dropping the course to avoid the stress of having to finish the project, although it was required for his major. He finally decided it was worth it to him to make good use of the effort he had already put into the project to complete the course and to accept the professor’s deadline extension, even if it meant doing some 152 Clinical Case Examples work over semester break. He and the therapist reviewed how the professor was much more accommodating, helpful, and nonshaming than Ian had predicted. Moreover, the main take away point was that Ian had the visceral experience of facing a difficult situation, took steps to deal with it directly, and achieved a resolution, albeit somewhat late, in this case. Ian finished the semester with average grades in his classes and completed the overdue project by the extension deadline. Preparations for the next semester involved the plan of Ian attending office hours for the instructors for each of his classes at the start of the semester in order to get “face time” with each of them to make it easier to reach out to them later in the semester, if he needed help. This plan also represented an exposure task to help him address his social anxiety and be able to reach out and advocate for himself. College students with ADHD often try to sidestep instructors’ attention, in part due to memories of past criticisms, as well as a sense of shame and embarrassment about their difficulties. Another source of avoidance is the thought that bringing up one problem may reveal other problems of which they were not aware, akin to the cliché of avoiding a physical exam for worry that a physician will find something wrong. Ian continued to make slow, steady progress across semesters, completing all of his credits for the first time since his freshman year. He was invested in CBT and began using the coping strategies more consistently. His parents also witnessed his improvements, noting that he seemed to be more optimistic and willing to face challenges that would have been overwhelming for him before. He encountered some slipups along the way that he and was able to manage without them interrupting his progress. In fact, he completed enough credits that he was graduated a little before his 25th birthday, before he got “old.”

Case Example 3: Jason Jason is a single 29-year-old man with a long history of treatment for substance use, specifically opioid dependence, starting in late adolescence. He presented for assessment for ADHD at the urging of his family after they felt his recovery efforts had “stalled,” despite being in sustained remission for about a year. That is, he lived at home and worked a variety of short-term jobs. However, when these jobs invariably did not pan out, he returned to work in the family business to have something to do. Otherwise, Jason was unable to sustain employment or any structured routine that was not exter- nally imposed by his parents or an intensive treatment program. Although they got

Downloaded by [New York University] at 12:14 14 August 2016 along well, neither Jason nor his parents were satisfied with the current arrangement. Jason was ambivalent about pursuing an assessment for ADHD but did so to appease his parents. He acknowledged that he had initially been in denial about his substance use problems, but had come to accept and deal with them over the past few years, having maintained sobriety for almost a year. Hence, he tried to approach the evaluation with an open mind and viewed it as something that might be helpful. Jason was in ongoing treatment with an addictions psychiatrist, whom he had seen since completing an inpatient rehabilitation program. The psychiatrist prescribed a regimen of combined preparation of buprenorphine and naloxone for treating opioid cravings and an antidepressant for depression. Jason also had been meeting with an addictions counselor, but stopped after feeling he was not making progress once his Clinical Case Examples 153 sobriety was stabilized. At the time of the evaluation, Jason neared his 1-year anniversary of being clean and sober, thus his substance dependence was essentially in sustained remission. He agreed to go through an evaluation for adult ADHD after his parents performed some research and wondered if there was a connection between ADHD, substance use, and his current sense of being stuck.

Assessment Jason’s parents participated throughout the evaluation process, both during the interview and by completing observer reports of various inventories about their son’s functioning at various times in his life. Jason was forthright and open throughout the evaluation, being noticeably restless and fidgety, shifting in his seat, though not exhibiting agitated mood or affect—he simply had trouble sitting still. During most of the past year living with his parents, he had been focused on his sobriety. He significantly limited his activities to things he could do around the house to help his parents, often staying awake until the early hours of the morning and sleeping until early afternoon due to not having any commitments. He kept up with all of his appointments with the help of his parents’ prompting. Jason eventually started working in order to have more structure and eventually to move out on his own. However, he experienced a variety of problems from not showing up, becoming bored, or quitting for some other reason. As his mother noted, Jason seemed to have reached a healthy plateau, but the “crisis” now was one of inertia and lack of initiative. Jason agreed with his parents’ characterization, clarifying that his ultimate goal is to establish an independent, fully functioning, sober adult life. The family’s collective goal for the evaluation was to determine if ADHD provided an explanation for Jason’s difficulties moving ahead in life and, if so, coming up with a plan for addressing it. Structured diagnostic interview indicated that Jason continued to endorse residual symptoms from depression despite being on an antidepressant. These depressive features seemed to represent ongoing frustrations and dissatisfactions with his current situation. There was a history of opioid dependence, in sustained remission by the time of the evaluation; however, there was also evidence of Generalized Anxiety Disorder related to worries about his ability to follow through on his goals. Jason said he recognized that he was “behind” developmentally because his addiction had interfered with his opportunity to accumulate life experiences, such as college, employment, relationships, etc. He described being worried that others would hold a negative view of him due to his various

Downloaded by [New York University] at 12:14 14 August 2016 setbacks. Finally, the possibility of bipolar disorder was thoroughly assessed, particularly considering his substance use history, his dysfunctional sleep habits, and his fidgety presentation. Although notably restless, Jason did not exhibit any of the characteristic features of reduced need for sleep, hypomania/mania, or agitation seen in the bipolar spectrum disorders. Rather, he presented as physically and mentally restless. The lack of a structured schedule and his love of watching television and playing video games for hours at a time resulted in a maladaptive shift in his sleep-wake cycle. Jason’s developmental and academic history, corroborated by his parents and their recollections of teachers’ comments, represented a developmental profile consistent with ADHD. Review of specific symptom measures and ADHD inventories documented that there was emergence of symptoms in childhood that persisted through to adulthood. 154 Clinical Case Examples Responses on the various ADHD inventories reflected a pervasive pattern of symptoms of both inattention and hyperactivity/impulsivity cutting through most domains of life, including during periods of sustained sobriety. More importantly, the childhood emergence of symptoms and difficulties clearly predated the onset of the addiction and mood problems. Jason’s performance on neuropsychological screening tests indicated problems related to auditory working memory as well as wide-ranging difficulties on a continuous performance task. His intellectual functioning fell in the average range, except for his performance on a block design task assessing nonverbal processing, which fell in the low average range. Jason eventually completed the designs but did so outside the time limits. Moreover, the tester observed that Jason was easily frustrated and seemed very embarrassed by his performance. With regard to family and developmental history, Jason’s parents were in their mid-50s and had been married 30 years. His father owned a successful business and his mother worked a variety of part-time and volunteer positions. Jason worked for his father’s business at various times for structure, money, and, as his father said, “so I can keep my eye on him.” Jason’s father mentioned that he had come across adult ADHD in the course of his research on addictions and treatments that might benefit his son. Both parents recalled that Jason had been “on the go” since he was an infant crawling around on the floor. They said that they had to put safety locks on all the cabinets and, as he started to walk and climb things, made sure that furniture was situated in a way that he could not climb too high. Despite these precautions, they said that he was always “getting into things” and that he often got bumps and bruises from roughhouse play. They said that he was not intentionally destructive and that he had a pleasant personality but that “his battery never seemed to need recharging.” Academically, his grades were “passing,” but teacher comments indicated that his work habits were inconsistent. His parents said that they had to monitor his homework to make sure that he finished it and that he remembered to take it with him to school. Jason recalled he did not have patience for reading and had difficulties with mathematics once he reached middle school and beyond. His parents noted that at least one of Jason’s teachers and one athletic coach suggested that he might have ADHD. Homework and papers were completed at the last minute, with many teachers being lenient on him for late assignments and allowing him to do extra credit assignments to bring up low grades, in part due to his athletic prowess. Jason was passionate about athletics. He was an all-district lacrosse player and was a

Downloaded by [New York University] at 12:14 14 August 2016 middle- and long-distance runner on the track team. Jason reported he never smoked cigarettes, drank alcohol, or tried drugs until his junior year of high school after he suffered a badly broken ankle during preseason lacrosse practice that required him to miss the whole season. There were complications in the healing where the ankle had to be rebroken and reset. Thus, he was immobilized for an extended period. The setback also meant that he would miss the track season. Jason was prescribed opioid-based pain medications following the surgeries. He initially took them as prescribed, remembering thinking at the time he understood “how people get hooked.” As he recovered and started the rehabilitation process to prepare for the next lacrosse season, he suffered another break in the same ankle and required more surgery. He grew increasingly depressed due to inactivity, the loss of the camaraderie of being on a team, Clinical Case Examples 155 and losing the physical fitness he had just reestablished. Before his injuries, Jason’s coaches said that he was a likely candidate for an athletic scholarship to play lacrosse in college. It was at this time that his misuse of pain medications started and his addiction was triggered. Jason never went through any of the gateway drugs and, to date, has never had a drop of alcohol; instead, his drugs of choice were the opiates. There was no family history of substance use issues. Jason’s late teens and early 20s were colored by his drug use. Jason received extensive treatment since he was 20 years old, though exclusively in the domain of addictions treatment. He enrolled in one semester of junior college but dropped out after having difficulties paying attention in class, falling behind in his work, and eventually not going to class, instead getting high. He worked various jobs but did not last long at them, either becoming bored and not showing up, or quitting due to his addiction. His parents were distraught to witness his precipitous downfall, particularly when he was arrested for possession after being stopped for driving above the posted speed limit. After a few false starts with treatment, he was fortunate that his parents got him into a top-notch addictions program. His psychiatrist identified and treated his depression, and prescribed the combined preparation of buprenorphine and naloxone to provide an additional deterrent to further opioid use. Jason said that while it was helpful to live at home over the past year, he now felt “stuck” in terms of trying to move forward in his life. At the feedback session for the evaluation, clinical evidence was laid out that Jason’s was a pretty clear-cut case of ADHD predating his drug use. He had been able to earn passing grades in school and athletics had provided a positive outlet for his energy. How- ever, his injuries wrecked the structure and outlet offered by athletics and also revealed the magnitude of his behavioral disinhibition. These losses and subsequent inactivity led to the onset of depression, resulting in his opioid abuse, which unfortunately was a convenient option for him. As he faced the prospect of maintaining his recovery and rees- tablishing his life, he experienced mounting anxiety. In effect, Jason had the opportunity for a “do over” in his life but did not have the requisite skills to do so on his own. It was agreed that Jason would continue to meet with his addiction psychiatrist and that treatment for ADHD would be concurrent with his ongoing recovery. Medication options for treating ADHD were reviewed in general terms, although any final decisions would be made by the addiction psychiatrist in consideration of Jason’s overall well-being, that is, his sobriety. The possibility of a consultation with a psychiatrist for the Adult ADHD Program was raised, though it was suggested that this option should be reviewed with the addictions psychiatrist, who had provided wonderful treatment to Jason. Jason’s main interest was in

Downloaded by [New York University] at 12:14 14 August 2016 moving ahead in his life, which would be the focus of CBT.

Course of Treatment

Pharmacotherapy At presentation to the psychiatrist, Jason reported some mild anxiety but no depressive symptoms and no active opiate abuse on his current regimen of citalopram, buprenorphine, and naloxone. When describing his goals for medication treatment, Jason emphasized a wish to be more focused, less distracted, less restless, and less “hyper.” He admitted that he was a bit reluctant to take stimulant medication, but he was willing to 156 Clinical Case Examples try anything that would make it easier to get mobilized, to stay on task, and to complete projects at home and at work in a more timely fashion. After a conversation with his addiction psychiatrist, Jason was started on OROS methylphenidate (Concerta ® ) at 36 mg daily. This had virtually no effect on his target ADHD symptoms. The dose was incrementally raised to 72 mg, with minimal effects and virtually no side effects. After a second consultation with the addiction psychiatrist, an informed decision was made to increase his daily dose to 90 mg which resulted in a more noticeable effect. One further increase to 108 mg daily led to Jason reporting that he was finally feeling “calm inside” and that he was getting things done a lot more quickly and with a lot less procrastination. Of course some of these improvements could be attributed to his progress in CBT. Jason himself couldn’t tell if it was the medication or his learning new skills (like planning his day, getting back to regular exercise, and going to bed at an earlier time) that were responsible for the positive changes.

CBT Jason’s circumstances at the outset of CBT were both promising and daunting. His case was promising insofar as Jason was motivated, he and his therapist (who was the evaluating clinician) had established a good rapport, and, despite his extensive substance use history, Jason’s recovery and mood were currently stable. On the other hand, the daunting nature of Jason’s case was characterized by his initial goal for treatment: “I have to change everything.” The first CBT session focused on defining some personally relevant targets for treatment. The problem was that, while his current arrangement was not “good” for him with respect to establishing his independent life, it also was not “bad” because living at home had helped him establish his recovery. But beyond activities related to treatment and his sobriety he had essentially no other obligations. Thus, Jason had the opportunity to restructure his entire schedule from the ground up, the “do over” to which he had referred during the evaluation, but there was simply no pressing need (i.e., motivation) to do so. The initial steps involved having Jason consider what he would like to see himself doing in 6 months. The therapist explored Jason’s past experiences, activities, interests, etc. Jason commented that he had thoughts throughout the day that he “should be doing something other than watching television.” However, he had a hard time identifying options; when he did have an idea, it was too broad (e.g., get a job, exercise) and he returned to his typical routine.

Downloaded by [New York University] at 12:14 14 August 2016 One of the benefits of CBT sessions for adult ADHD is that they provide a block of time and a structure that helps patients stay engaged on a topic or a task, akin to the function served by behavioral inhibition. The therapist helped Jason to take some of his broad ideas for things to do and to start to break them down. Between defining longer range goals (e.g., get into shape, play a sport, get a job) and typical day-to-day tasks (e.g., help parents around the house, organize belongings, walk dog), Jason was able to win- now in on specific behavioral targets. Acknowledging that there would be many open spaces, Jason agreed to use a Daily Planner to record his action plans, monitor how he spent his time, and track his professional appointments. The early sessions were painstaking but productive. Jason had some good behavioral targets that eventually helped him to establish a more regular and adaptive schedule. At Clinical Case Examples 157 the outset, however, a great deal of time in session was devoted to devising implementation strategies so as to increase the likelihood that he would follow the behavioral plan, particularly because he had no external motivators, such as an employer, teacher, or girlfriend to whom he had to answer. Although he wanted to get back into shape, he had difficulties following through on various component tasks of the larger goal, such as going for a jog or researching local gyms. These broad action plans, however, provided an opportunity to identify these “pivot points” and then intervene. For example, problems following through with exercise steps helped reveal the influence of his procrastination thoughts (e.g., “I don’t feel like running right now.”), escape behaviors (e.g., “I’ll call the gym as soon as this movie is over. I’ll remember to do it.”), and the role of feelings of discomfort and embarrassment as he considered taking these initial steps (e.g., social anxiety about being out of shape). Cognitive interventions were used to develop task-oriented thoughts that, when combined with redefining the specific task, slowly led to increased follow-through (e.g., “Let me just start running and see what I can do. I’ll listen to music on my iPod while I jog. I’ll feel better having done something rather than not doing it.”). Consequently, Jason slowly added items to his schedule that provided anchors around which to schedule other tasks (e.g., “Do you think it would be better to call regarding the volunteer position before you go jogging or after?”). He also described using similar skills to keep up with tasks around the house, including being more diligent about managing personal finances and following through on simple chores to help out his parents. There were slipups over the first several months, but Jason was able to establish and maintain a skeleton of an adaptive schedule. He started to personalize various aspects, such as finding that he enjoyed bike riding for exercise more than jogging because it was easier on his ankle, which still got sore when he jogged. He also stumbled upon a weekly bike riding club that met for group rides near where he lived. Jason developed a morning routine that included reviewing his planner and defining specific tasks throughout the day, including some administrative tasks that helped establish a “flow” to his day. He noted that he did not watch television as much as he used to and that he did not miss it as much as he assumed he would. He said that it felt surprisingly good to get things done, even if they were chores or errands. Jason reported it was helpful to define tasks in terms of “behavioral scripts” to promote follow-through, and the cued reminder to “enter a room with a plan” helped keep him on track. Jason researched a few volunteer positions, but eventually decided he wanted to try to obtain a paid job. It turned out that Jason’s father had a genuine need for someone to fill

Downloaded by [New York University] at 12:14 14 August 2016 a variety of needs, including customer service, sales, and some other duties in his business that could be bundled together into a position. Jason would work 4 days per week, allowing him to have a weekday free for scheduling his treatment appointments. His father agreed that Jason would be held to the same performance expectations as other employees. Jason accepted the job, seeing it as being a stepping stone rather than a fallback option. Although he had the comfort of working for his father’s company, the job posed newfound challenges to his organizational skills. At first he was overwhelmed and questioned his ability to handle a “real” job. His all-or-nothing reaction was countered with the recognition he had exhibited real improvements in his coping skills at home which could be applied to his job. The metaphor of his interest in bike riding was used to 158 Clinical Case Examples illustrate that as he built up his fitness and endurance, he faced new challenges, such as riding longer distances or up steeper hills. Each challenge took a while to master but he eventually conquered it through practice and persistence. Defining tasks in specific behavioral terms helped Jason counter his tendency to magnify the difficulty of tasks he was given and to focus instead on what he needed to do. Even though his father pointed out how well he was doing, Jason often engaged in negative comparisons with other workers, finding examples of how he was not matching the performance of others. In fact, at some points Jason spoke of quitting his job, assuming he was not doing well and expecting he would be fired: reflections of the strength of his inadequacy and failure schema. Review of his reactions to specific situations revealed that Jason was on guard for being “exposed as a fraud.” He dismissed his father’s compliments on his performance as “coming from (his) father—what else is he going to say?” When asked about positive feedback from coworkers or customers, Jason attributed these compliments as either being the result of coworkers “sucking up to the boss by being nice to his son” or dismiss- ing them with a “yes, but” statement, such as “yes, but they just caught me on a lucky day:” indications of his self-mistrust about his abilities. Cognitive interventions were used to help Jason appreciate that he kept reaching the same conclusions regardless of the objective evidence or feedback. It was pointed out that Jason started the job assuming that he was “behind” everyone else and that every minor misstep confirmed this fact, while his more frequent successes were viewed as exceptions or “dumb luck.” The defense attorney metaphor was introduced as a strategy to help Jason see that he held himself to a standard to which he did not hold others. It was noted that this compensatory strategy made perfect sense, representing preemptive criticism—“I will be harder on myself than anyone else will in order to avoid having to hear (and feel) criticism.” However, it ended up reinforcing his inadequacy and failure schema because it forced him to scrutinize himself for any and all flaws. Jason started to develop a sense of competence by facing challenges at work. An important step in this regard was when he started to consider his preferences and his opinions, and that he could advocate for himself, which was a novel experience for him. With prompting, he started to identify situations in which he could express his opinions or set limits in a simple, straightforward and assertive manner, rather than feeling he had to accommodate others, even when it went against his better judgment. What is more, he learned that people seemed to respond well to him when he was just “being himself.” He eventually developed his own style of assertiveness, which also helped raise

Downloaded by [New York University] at 12:14 14 August 2016 his confidence. Jason and his therapist could not identify the specific day that it happened, but during a review of his progress during a session at about the 1-year point of CBT, Jason saw how far he had come since he started. He was in good shape and was a standing member of a local bike riding group. He continued to work for his father but had started to interview for other jobs and was preparing to move into an apartment with a friend of his. Jason was still prone to staying up too late at night, but his schedule was much more predictable and helped him get back on track. Both of his parents said that they found him to be more reliable and mature than in the past. Having established newfound stability in his life, Jason looked toward a new level of goals for the future, including expanding his social life (entertaining the prospect of Clinical Case Examples 159 dating), living on his own, and looking into a new job. These pursuits would raise the potential risk of slipping in his recovery, insofar as there would be increased likelihood of being exposed to substance use triggers. However, although not exactly a “do over,” Jason had taken some hugely important steps toward getting “unstuck” and moving ahead with his life from the point at which it had been interrupted by substance use.

Case Example 4: Harold Harold is a 50-year-old married man who lives with his wife and their two teenage children. He has been unemployed for the past year after working in the pharmaceutical industry in sales for a few years. He had worked in various sales-related jobs throughout his life, including automobiles and retail positions, and he was also a licensed real estate agent. Harold usually changed jobs after a few years, being familiar with brief periods of unemployment, but never as lengthy as the current stretch. Harold sought an evaluation for ADHD in a crisis after his wife, Carol, mentioned that she was considering a separation. While not quite “threatening” it, she was serious enough that it could not be dismissed as coming from the heat of the moment. A common theme of their marital therapy had been her frustration with feeling that she was left alone to manage the household and parenting duties as well as being the primary source of income and benefits for the family. What is more, the family faced dire financial straits due to his lengthy unemployment that required concerted maneuvering to avoid bankruptcy. Carol stated that she did not feel that she had a partner in the marriage. The marital therapist mentioned to them that their accounts of Harold’s various behaviors were consistent with her understanding of adult ADHD. Moreover, the therapist affirmed that Harold expressed a sincere commitment to the marriage but struggled with follow-through on important matters. Hence, it was recommended that he pursue an assessment for adult ADHD.

Assessment Harold missed his first scheduled evaluation appointment when he forgot about the meeting until late the night before he was to come in. He was unable to find the paperwork mailed to him and he called the office on the morning of his scheduled assessment to describe his predicament. It was decided to reschedule the meeting to the next available slot. When Harold arrived for the rescheduled assessment, he was accompanied by

Downloaded by [New York University] at 12:14 14 August 2016 Carol, and he agreed that it would be helpful to have her provide her input on his functioning. Harold attributed the loss of his most recent job to the poor economy, although his wife pointed out that he had been placed on a performance improvement plan and that, although economics played some role, all of his colleagues had met their sales goals and retained their jobs. Carol described Harold as hard-working and reported that unemployment was very difficult for him, both financially and from the loss of structure provided by a job. However, she said he was unreliable in his efforts to find a new job and inconsistent in other roles he played in the household and family. For his part, Harold agreed that his jobless year had been difficult. He felt more depressed and anxious, which further interfered with follow-through on tasks related to 160 Clinical Case Examples his job search and other aspects of daily life, which were already difficult enough for him to manage. Even when he had been employed and “meeting his numbers,” he said that he had problems following the various policies and procedures involved with finalizing transactions. Harold said that most of his performance review meetings started with, “Everyone here and your customers really like you, but . . .” Carol said that while the struggles over the past year brought various issues to a head, leading them to seek marital therapy, there had been many other problems simmering for a long time. She took over responsibility for managing the household finances from Harold after various incidents of paying late fees, having services discontinued due to nonpayment, and reaching spending limits on credit cards. Carol also stated that she could not count on Harold to take care of errands, such as picking up their children from activities, helping out with homework, taking on some household chores, or various other parental duties. He said that he would agree to a task and want to help out Carol, but would then forget or get engrossed in a sale or project at work and would lose track of time. Carol said that Harold was a loving father and was truly remorseful about his mistakes, but his behavior remained “consistently inconsistent” and she was always left dealing with the fallout. Harold was embarrassed by his erratic behavior and grasped his wife’s dismay. He said that he had always been disorganized and not good at details, considering himself a “big picture” thinker who was very good with people. Harold recalled having difficulties organizing and managing his schedule at work apart from his struggles at home. He said he grinded through the week at work and used weekends to catch up on various leftover administrative tasks and paperwork. While he always felt busy, he never seemed to get done all that was required. Harold’s main goal for the evaluation, whether or not he ended up being diagnosed with ADHD, was to figure out the source of his difficulties and to develop a treatment plan for making positive changes in his life. More specifically, he said that he wanted to be better organized in his job search and in his duties at home so as to demonstrate his commitment to his wife. Structured diagnostic interview indicated that Harold endorsed many symptoms of both depression and anxiety. His depressive symptoms never exceeded diagnostic thresholds for a Major Depressive Episode, but rather seemed to reflect Dysthymic Dis- order, emerging around the time of the birth of their youngest child, when he said he was faced with the enormity of his responsibilities as a parent. Harold also reported he experienced anxiety and periods of being “keyed up” at times. Further exploration suggested that what he was describing seemed most consis-

Downloaded by [New York University] at 12:14 14 August 2016 tent with mild hypomanic episodes. For example, during college he described a couple periods of extreme productivity in his catching up on schoolwork as well as being able to follow through on other things he had to do, although this “mode” would soon fade away after about a week. He said that he continued to have one or two of these periods of energy and productivity each year, but that his mood generally fell toward the depressive end of the continuum, not every day but more days than not. If anything, his presentation was that he did not have sufficient anxiety about many of the difficulties he was facing. Consequently, Harold’s comorbidity presentation seemed consistent with Cyclothymic Disorder. As part of the assessment, Harold and his wife completed ratings of his current functioning; he recruited his older brother to complete ratings of his childhood behavior. Clinical Case Examples 161 Regarding his childhood behavior, Harold exhibited prominent features of both inattentive and hyperactivity/impulsivity symptoms. When asking him to complete observer forms, his brother reminded Harold of various incidents in which their parents had to take Harold out of a restaurant or a movie theater for “fidget breaks.” There was a family rule that everyone was required to sit together for dinner until a reasonable point of completion, but Harold was allowed to stand or walk around as long as he stayed within the dining room. Being a few years ahead of him in school and having many of the same teachers and coaches, his brother also recalled various problems Harold had at school. Harold recalled these incidents but had not considered them as elements of a pattern that might reflect ADHD. In terms of current functioning, Harold and Carol both endorsed high levels of hyperactivity/impulsivity and inattention symptoms, as well as difficulties in all domains of executive functioning, with Carol providing higher severity ratings than he did. When discussing some specific examples of difficulties, Harold put a “positive spin” on various incidents (e.g., “Yes, they fired me but I ended up in a better job.”), emphasized external factors (e.g., “That supervisor never liked me.”), or deflected attention away from personal responsibility (e.g., “They were rigid about their sales staff following their procedures— they should have been more open-minded about different styles.”). If only his performance on neuropsychological screening measures was considered, the case for ADHD would not have been as strong. His intellectual functioning fell in the average to high average range, with his verbal intelligence falling in the superior range. He exhibited mild deficiency in auditory working memory, but no attention difficulties were found on a continuous performance task of attention. Harold observed he was usually able to focus on one task at a time in the testing session, but had difficulties juggling multiple tasks in daily life, which was better reflected on the executive dysfunction rating scale. There was history of depression and anxiety on the maternal side of the family. Har- old described his mother as the CEO of the family, remembering his father as a “TV junkie,” to which Harold’s wife retorted: “The tradition continues except that Harold also is a computer junkie.” Harold’s mother reportedly took prescribed antidepressants. Carol observed that Harold’s parents stayed married but seemed to be living parallel lives rather than being in a functional marriage. Last but not least, his older brother was diagnosed with ADHD as an adult and was finding benefit from treatment. This older brother also provided a written summary of his recollections of Harold as a child. He was described as energetic, on the go, and always had to have things “done his

Downloaded by [New York University] at 12:14 14 August 2016 way.” It was also noted that Harold could be “emotional,” getting upset if things did not go his way and “throwing tantrums” that would draw attention when carried out in public. As he got older, his brother reported that Harold continued to be “headstrong” and that, although not a troublemaker in terms of acting out behaviors, he could be argumentative and oppositional when he disagreed with rules or authority figures. On a few occasions, he quit or was dismissed from a sports team for not following rules or directions, although these situations were usually smoothed over. His grades throughout primary and secondary school were average. Harold said that he felt that he could have done better but he either rushed through homework to “say (he) got it done” when his mother watched over him or he simply put it off or did not do it when she was not around. His brother said that he and his sister were assigned the task 162 Clinical Case Examples of “looking after Harold and make sure he does his work” when his mother was not available, which resulted in resentment on the part of the sister. Harold attended a large state university for college. He was placed on academic probation after the first semester, stating he had difficulties handling his newfound independence and the corresponding lack of structure. His class attendance was poor, he passed his classes by cramming the night before, and he admitted that he blatantly pla- giarized two term papers, getting copies that had been submitted by another student a few years before. Harold was enrolled in college over a 6-year span owing to a mix of dropped or failed courses, and simply dropping out for two semesters. He eventually took off a semester during what would have been his final year, but he never returned to school and thus never graduated. During his semester off, a friend convinced Harold to try a computer sales job. Harold performed well in this setting and was able to learn a lot about computers through his hands-on experience. This was good timing as it was during the advent of the personal computer boom. He decided to keep working, planning to earn money before returning to finish college, but he earned a good income and kept working in computer sales and related technologies for several years with the same company, representing his longest tenured job to date. Despite his sales skills, Harold had difficulties keeping up with the increased complexity of the technology field, including reading technical manuals and completing software certification courses. The fact he had not finished college limited his job options so he had to find employers who valued his sales skills. Carol said she met Harold during the first year of one of his jobs. She found him to be charismatic and fun. They dated for about a year before deciding to live together after getting engaged. He moved into Carol’s apartment at the same time he was let go from a job. Having a stable work history as a nurse, it was disconcerting for Carol to witness her husband-to-be’s job loss. However, he reassured her that this was common in sales and that he would soon find a new job, which he did within 6 weeks. After getting married and starting their family, Carol grew accustomed to his pattern of serial employment. What is more, she witnessed the effects of Harold’s disorganization and poor follow-through in their daily lives. She remembered being disappointed by his lack of help after she returned to work following the birth of their first child. As their family grew, she was overwhelmed trying to keep up with their children’s academic and extracurricular activities while maintaining a full-time job, noting the stress of being the reliable wage earner and the one whose job provided the family’s health care benefits. Carol observed that Harold seemed to come home and spend most of his time on the

Downloaded by [New York University] at 12:14 14 August 2016 computer, often staying up into the early morning hours. Harold admitted that he is captivated by technology and owns and makes use of a full assortment of electronic gadgets, such as a smartphone, computer tablet, laptop, etc. as well as social networking and other online services. Said differently, he had the capacity to be “wired” at any time. Although starting off as legitimately “checking something for work,” he often ended up playing computer games and researching trivial matters, further interfering with his availability to lend a hand around the house. Harold’s represents a moderate-severe case of ADHD and related impairments in adult role functioning. He had the benefit of “scaffolding” and a number of other supports that helped him compensate for ADHD over the years. Harold also exhibits features of chronic cyclothymia that developed after ADHD, though there is also evidence of low-grade, Clinical Case Examples 163 persistent oppositional behavior that predates his mood issues and emerged along with ADHD. His oppositional behavior persists in adulthood when faced with frustrations, particularly related to others’ performance expectations for him (i.e., wife, employers). More- over, the frequency and extent of his technology use represents an important clinical issue inasmuch as it contributes to his procrastination and overall task avoidance. There were some encouraging prognostic factors. Harold’s intellectual functioning was strong and he exhibited occupational resilience in the past. Although initially ambivalent about the diagnosis of ADHD, discussions with his brother helped prime him for the evaluation. Tears filled his eyes as he considered the fact that his wife had considered a separation from him. He began recognizing the impact of his behaviors on his loved ones throughout life, including his sister. Consequently, he expressed strong motivation to make changes in his life. In light of the severity of his symptoms and his comorbidity profile, it was recommended that Harold start a combined treatment protocol of medications and CBT for adult ADHD. His brother had found medications helpful in his ADHD management plan and Harold was open to having a psychiatric consultation. Harold also agreed to pursue CBT (concurrent with marital therapy) with an initial focus on helping him organize and follow through on tasks related to his job search.

Course of Treatment

Pharmacotherapy At his initial visit with the psychiatrist, Harold admitted that he was very doubtful that medications would be beneficial for him. He also expressed some resentment about the fact that he might have to “take drugs” for the rest of his life. After discussing the pros and cons of pharmacotherapy in general, and the possible medications that might be considered in his case, Harold was given some materials to read instead of being given a prescription. He returned 2 weeks later prepared to discuss the advantages and disadvantages of the various options proposed to him at the first visit and generally more positive about his choices. It was decided to begin a trial of extended release mixed amphetamine salts (Adderall XR® ) 10 mg daily, and to increase the dose to 20 mg and to 30 mg in order to determine the optimal dosage. He was advised to keep records of his responses to the various doses (using the Medication Log introduced in Chapter 2) and to ask his wife for her opinion of the changes she might see in him.

Downloaded by [New York University] at 12:14 14 August 2016 At the follow-up visit, it was determined that 20 mg was the best dose for Harold. The lowest dose was ineffective, and the higher dose caused him to experience insomnia and to feel “too wired.” On the 20 mg dose, he found he could focus better and could get himself “motivated” more easily when facing unpleasant chores or tasks. A single daily dose was prescribed, which he reported lasted about 7 hours. He was advised that if and when he found a job, he could take a second dose of medication in the early afternoon in order to give him coverage for the entire workday and for evening “family time.” Despite the reported improvement in his ADHD symptoms, Harold found it disconcerting that he needed a medication to get things done efficiently and effective. He often would skip doses because he “forgot” to take it, and he frequently ran out of pills because he had failed to ask for a refill from the psychiatrist’s office in a timely fashion. 164 Clinical Case Examples CBT Harold called to reschedule his first CBT meeting, ostensibly due to a scheduling conflict, but later admitted that he had forgotten the day and time of the appointment. He was apologetic when he arrived for the rescheduled meeting, joking that his poor tracking of commitments was a recurring problem that could be a target for CBT. Harold agreed with the therapist’s suggestion that they spend some time reverse engineering this example of a larger treatment issue. At the evaluation feedback session Harold had been given an appointment card with the day and time of his first CBT appointment and contact information to arrange an initial meeting with the program psychiatrist. He said he put the business cards in his pocket with the intention of later adding them into his smartphone. However, he “never got around” to transferring the information. At various time, his wife asked him if he had called the psychiatrist or wondered aloud if the first CBT session was coming up soon, to which Harold glibly responded with “I’m working on it.” He stumbled upon the appointment card the day before the session. In fact, Harold concealed from his wife the fact that he missed his first CBT session out of a sense of shame and an expectation that he would get “that look” from her. When asked the meaning of “the look,” he said it was a look of “disgust and disappointment” with him. When asked to consider his thoughts about entering the information in his smartphone at the time they were scheduled or at times when Carol reminded him, Harold admitted he was miffed at “being told what to do.” The therapist helped Harold see the connections between his ADHD and his reactions to tasks, in this case scheduling an appointment, including his feeling of annoyance. This pattern likely contributed to his oppositional reactions insofar as he is sensitive to being put into situations where his weaknesses are exposed, harkening back to him having to have things “done his way” when he was younger. He admitted to being sensitive to appearing as a “failure” and a disappointment, and to getting angry if others pointed out his shortcomings. Thus, the difficulties associated with keeping the first appointment were framed as the skill of organizing and following through on valued tasks, which also were relevant for handling his job search. As a first step, Harold was encouraged to keep track of how he spent his time and energy in the coming week using a Daily Planner. Harold doubted that this seemingly small step would be helpful, noting that “I need to find a job first.” The therapist invited Harold to “do an experiment” to gain more information about how he current “spends himself” and observe his reactions to different tasks, including those Downloaded by [New York University] at 12:14 14 August 2016 pertaining to his job search. Harold agreed to give it a try. Harold returned at the next meeting and reported difficulties with his homework. He decided to use the calendar function on his smart phone to track his schedule. Although he entered his CBT session and set the alarm function while in the therapist’s office at the end of his previous meeting, he rarely referred to the calendar function during the week to track his schedule. He said he remembered the CBT assignment at various times, but figured he “would fill it in later.” Harold judged the experiment as unsuccessful, but the therapist noted that it yielded useful information: Perhaps Harold should not rely on the smartphone for scheduling and planning. Moreover, he provided some vague accounts of looking for a job but Clinical Case Examples 165 nothing productive. Harold and the therapist first reviewed various other planner options, with the therapist suggesting the use of a paper Daily Planner. Harold was reticent to try the planner, stating that he had tried different ones in the past and they did not work for him. The therapist explored how they did not work, hearing a common assortment of experiences: “I lost it,” “I forgot to bring it with me,” and, more recently, he got out of the habit of using one since he had been unemployed. The first two complaints were addressed as executive function issues rather than the effectiveness of the planner as a tool. The issue of getting back into the habit of using a planner was deemed a separate issue. Harold said that he had so few commitments that using a planner seemed to be a waste of time and effort. Harold was encouraged to use a straightforward planner that allowed him to view a week at a time when it was opened. Moreover, it was to be used for professional appointments as well as for personal tasks. Harold agreed to the therapist’s suggestion but said that he wanted to give the smartphone one more try before committing to a traditional planner. Harold recognized the degree to which he procrastinated on his job search based on the sense of being “watched” by others, that is, Carol and her family, insofar as they are invested in the outcome; therefore, he felt open to potential criticism and failure. Conse- quently, he experienced discomfort associated with the task despite logically recognizing the need to find a job. He and his therapist discussed Harold’s implementation plans, defining some specific times he could work with the calendar function on his phone with regard to his job search. Harold identified some candidate times to engage in a job search in the coming week. He defined some specific job search tasks, including making a list of five specific compa- nies to explore, and going through listings on job search sites. To enhance the likelihood of follow-through, Harold was asked about likely distractions he would face and his coping response to each one (e.g., “If I think about another task I could do around the house, I will write it down and will do it after I finish my scheduled job search.”). When asked for a reasonable time frame to spend on an online job search, Harold said “3 hours.” In light of Harold’s observations of emotional discomfort associated with the job search, the therapist asked about the likelihood of him sitting down for 3 hours on what he viewed as such an uncomfortable task. Instead, the therapist asked Harold to consider the briefest time frame in which he could make some headway on a job search as a means for helping him to get engaged. Moreover, Harold’s initial apprehension about the job search was normalized and anticipated. Cognitive reframes were used to

Downloaded by [New York University] at 12:14 14 August 2016 maintain a perspective that he could tolerate and accept discomfort and follow through with the initial steps of the task, anyway (e.g., “I can feel initial discomfort and still access websites for potential employers. I will feel better taking these steps.”). Harold said that the plan sounded rational but added, “I cannot accomplish enough unless I devote at least three hours to it.” When asked about recent examples of engaging in a job search, he cited a few late night sessions where he spontaneously started looking at job sites after playing on the Internet. He said that he ended up having productive searches lasting a few hours, evidence for Harold that he must rely on spontaneity or “being in the mood.” Rather than disagreeing with Harold, the therapist pointed out that his impromptu late night work sessions did not start out as three hour session, but started with him looking into a single job lead, which got him started. The therapist 166 Clinical Case Examples noted that Harold found a way to “start small” and get engaged by “lowering the bar,” which resulted in a productive session. This motivational enhancement approach also helped the therapist align with the patient’s oppositional tendency and redirect it toward adaptive coping. Harold said that he would attempt the suggested coping strategies, but questioned if they would work for his unique circumstances. Harold was encouraged to give them a try but to monitor in detail the difficulties he encountered. Harold rescheduled his next meeting twice, stating he was engaged in some projects at home on which he was making progress, including identifying some job leads. A month had passed by the time he attended his next session of CBT. At the meeting, Har- old reported that he thought he had made some progress keeping up with some household projects. When asked about his job search, he said that he tried to implement the tactics discussed at the last session and they worked on some days but not on others. Harold had submitted some online applications but had not yet gotten a response. He reported that he had decided to put the job search “on hold” to focus on some of his projects at home, including trying to sell some old furniture and other items online in order to bring in some money. The therapist encouraged Harold to weigh the pros and cons of this plan, including Carol’s reaction. Harold replied that he felt the medications were helping but that the job market was not good for him right now. The therapist tried to engage him in developing other options, such as contacting old associates or identifying and reaching out to potential employers. However, Harold was resolute that trying to sell various items online would offer him a flexible task he was motivated to perform and would bring in some money quicker than would focusing on a job search. He admitted that Carol was upset when she pressed him about his plan but he was convinced that she would come around when she saw the money he would get, adding that he simply needed his wife to trust his way of doing things. The therapist observed that Harold seemed to expect others to accept his plans without disagreement. The therapist noted that Harold’s success in his sales career seemed to be his ability to adapt to new products, customers, and markets. Perhaps, he could similarly experiment with a wider range of search strategies as well as adapt to his first job search during which he was aware of the impact of adult ADHD. He admitted that he saw that Carol was upset by his inconsistency, and that sorting through items to sell gave him a “hands-on” project instead of the uncertainty of a job search. Harold was more collaborative in developing his behavioral script for his job search efforts before the next session, as well as specific implementation plans for handling procrastination. It was

Downloaded by [New York University] at 12:14 14 August 2016 noted that scheduling job search times would leave him with more than enough time to sell items online, rather than viewing it as an all-or-nothing proposition. At the next session, Harold said that he completed his homework goal of applying to five jobs but waited until the night before the session to do it. He said that he found the written directions helpful but had difficulties committing to specific time blocks for the job search. Strategies for explicitly generating “enough” motivation for tasks (i.e., thinking through the benefits, challenging negative assumptions and feelings, and using other cognitive rehearsal and exposure strategies) were used to help Harold get engaged in tasks. He admitted that he felt a combination of satisfaction and relief after submitting the applications and seeing that Carol was very supportive of him. Harold anticipated applying for even more jobs in the coming week. Clinical Case Examples 167 Despite having a better understanding of the effects of ADHD on his behavior and exhibiting some degree of follow-through on tasks, Harold did not yet seem to embrace the coping strategies, and his attendance to sessions was inconsistent, attending a few sessions in a row before missing or rescheduling sessions. His oppositional patterns were manifested in wanting to do things his way, such as finding small faults with coping skills to justify the fact he did not use them or did not obtain the desired results, perhaps reserving the option of blaming CBT (i.e., externalizing) as a compensatory strategy. Har- old said that he thought his core symptoms improved from the medications and that he was more responsive to Carol’s requests for help around the house. However, he continued to remain stuck in terms of follow-through on his job search and on other high- priority tasks. Various interventions were employed aimed at increasing Harold’s use of coping strategies: Scheduling phone check-ins and e-mail reminders between sessions to reinforce coping principles, inviting Harold to e-mail daily plans to the therapist to have external accountability, etc. With Harold’s permission, his wife attended two sessions. She reported their respective families had each given them generous financial gifts to help ease their money problems. Moreover, Carol had cooled on the idea of separation, although she did not consider the marriage to be very strong. She noticed some improvements in Harold’s follow-through on tasks around the house while on medications, although this was achieved at the expense of time better spent on the job search. She observed that he seemed to be using some of the strategies and “scripts” developed in CBT but not as much as she would have wished for. Harold eventually obtained a job arranged for him by a colleague of his father-in-law about 9 months into treatment. Harold said he would be in touch to resume sessions after he got settled in the new job, although Carol thought he should use sessions to handle his follow-through at work. Harold eventually reached out to the therapist about 3 months later, after concerns were raised during his first performance evaluation. He attended two sessions and Harold was receptive to a focus on coping skills that applied to the job. During these sessions, the therapist encouraged him to reconnect with his psychiatrist in order to reexamine the risk-benefit ratio of medications to help Harold handle the demands of work. Alas, he cancelled his next meeting. To date, Harold continues in CBT in an off-and-on manner. This is a less-than-ideal arrangement, but at least he has a therapeutic connection and a place to address his concerns. He remains employed in the same sales job and has just passed the 1-year mark, though his performance evaluations have been lower than he typically achieves

Downloaded by [New York University] at 12:14 14 August 2016 during the “honeymoon” period. He said that he has found it useful to lower the bar and develop behavioral scripts to break down tasks into manageable steps. Overall, Harold described his current status as “better, but not great.” Obtaining the job helped alleviate the family’s financial difficulties and addressed some of the marital stress inasmuch as Harold had a structured schedule. He benefitted from financial support from his and Carol’s families during his unemployment and from the fact he was handed a job opportunity he did not seek out, both of which reinforced his unrealistically positive belief in “breaks.” Harold’s case represents some of the challenges of complex adult ADHD and associated functional impairments encountered in typical clinical practice. Moreover, despite improvements on follow-up ADHD symptom ratings, Harold continued to exhibit 168 Clinical Case Examples important functional impairments masked by various environmental supports provided to him. His ambivalence about medications and what they mean to him likely underlie the fact he has discontinued psychiatric treatment for all intents and purposes. In similar fashion, many adults with ADHD live on this sort of a razor’s edge of functioning where even mild disruption may result in a precipitous fall. Consequently, some adults with ADHD will require a longer course of treatment to deal with the various ebbs and flows of functioning. Moreover, they benefit from a therapeutic alliance that provides them with an anchor—especially when they are drifting out to sea.

Downloaded by [New York University] at 12:14 14 August 2016 5 Complicating Factors

Findings from a range of clinical outcome studies indicate that cognitive behavioral therapy (CBT) paired with pharmacotherapy will be helpful for most adults seeking treatment for Attention-Deficit/Hyperactivity Disorder (ADHD). However, clinical practice with “free-range” humans abounds with complicating factors that may get in the way of achieving optimal outcomes. In fact, the same core symptoms and executive dysfunction and motivation deficits characteristic of ADHD interfere with the effectiveness and delivery of treatment, from keeping up with prescription refills to implementing psychosocial coping strategies, not to mention simply attending scheduled appointments. An ADHD-informed CBT case conceptualization provides a useful framework for understanding and addressing many of the complicating factors that arise in treatment. In many cases, these troubles represent aspects of the myriad manifestations of ADHD. The therapeutic task is to generalize the application of coping strategies to these issues as they surface. In other cases, however, complicating factors represent knottier, idiosyncratic therapeutic issues that intersect with and are made more difficult to manage by the presence of ADHD. If these complexities and frustrations are not adequately addressed, many adults with ADHD are at risk to drop out of treatment altogether, consequently losing potentially helpful therapeutic support and insidiously reinforcing the sense that “nothing will help me.” On the other hand, effective management of such potential obstacles can maintain, if not accelerate, therapeutic progress. At the very least, the successful navigation of these issues provides opportunities for adults with ADHD to gain confidence in their abilities to handle problems they used to avoid, thereby developing a greater sense of resilience. What follows is a review of some commonly encountered complicating factors that arise in a course of treatment for adult ADHD. We have modified this chapter from the

Downloaded by [New York University] at 12:14 14 August 2016 first edition of the book. We revisit a few of the most commonly encountered difficulties and cover some new topics. The sections from the first edition of the book not included here remain clinically relevant, but the revised edition offers an opportunity to expand our coverage of the sorts of issues encountered by practicing clinicians who work with adults with ADHD.

Readiness for Change and Motivational Enhancement in CBT Participating in treatment for adult ADHD is not a passive process. CBT requires a degree of motivation and commitment to follow through in order for patients to obtain the best results from what treatment has to offer. However, by its very nature, ADHD is 170 Complicating Factors a disorder characterized by difficulties defining and implementing plans over time to achieve a desired outcome, with poor motivation being a ubiquitous problem. Thus, although after receiving the diagnosis of ADHD, many patients are eager to start treatment, some individuals may find that they are unsure about their readiness to make such a commitment. Even once engaged in treatment, patients with ADHD will likely experience difficulties implementing many of the coping skills. With respect to the decision of whether or not to start treatment, we (and many other clinicians) have found Prochaska and colleagues’ stages of change model to be very helpful in conceptualizing and intervening with patients’ attitudes toward the diagnosis and treatment of ADHD (Prochaska, DiClemente, & Norcross, 1992; Prochaska & Norcross, 2001). This transtheoretical model was developed from research on how people change addictive and health-related behaviors, which are notoriously difficult behaviors to modify. Considering the chronic and pervasive nature of ADHD, it has proven to be a useful framework for tailoring interventions to the needs of each patient. In particular, patients who are deemed to be in either the precontemplation or contemplation stages, characterized by denial of problems or begrudging recognition of some problems paired with ambivalence about making changes, respectively, may not be ready to commit to doing the work required of CBT or pharmacotherapy for ADHD. In fact, some individuals who feel “mandated” to attend treatment can be considered to be in a stage of anticontemplation (Freeman & Dolan, 2001) in which they are actively opposed to engaging in the change process. For such patients, it is clinically appropriate to spend time exploring their thoughts about their circumstances, what is called “consciousness raising” (Prochaska et al., 1992). To this end, portions of sessions or even several sessions in some cases are spent identifying assumptions individuals hold about ADHD, treatment, or their ability to change. Reviewing the relative costs and benefits of changing versus staying the same also can be useful to clarify patients’ readiness for treatment. Motivational interviewing techniques are used to find examples of areas of dissatisfaction in personally relevant domains of patients’ lives for which they be motivated to address, or at least further explore (Miller & Rollnick, 1991). As has been noted elsewhere, the intervention of defining problems in terms of specific examples and in behavioral terms helps to disentangle the diverse relevant therapeutic issues. Simply asking about “what could be better” without referring to ADHD is a way to get the conversation going. Matching the pace and focus of therapy to individuals’ particular stage of change helps decrease the likelihood of patients dropping out of therapy, particularly in cases of ambivalence. There are subsequent phases in the stage of change model through which individuals

Downloaded by [New York University] at 12:14 14 August 2016 may cycle several times, often simultaneously exhibiting characteristics of several different stages. The preparation stage reflects efforts to implement some minimal behavioral changes but without a commitment to making wholesale modifications. This is commonly observed in patients with ADHD who have not yet grasped or are ambivalent about the daily coping steps needed to adequately manage ADHD. Once patients have fundamentally changed their coping patterns in adaptive and sustainable ways, they are considered to be in the action stage. The therapeutic focus shifts to reinforcing and maintaining these new coping behaviors and handling inevitable slipups and setbacks that ordinarily arise, again, and which are “par for the course” in ADHD. Finally, the maintenance stage refers to the point at which the adaptive coping patterns have become solidified as the new behavioral norm. The maintenance phase is Complicating Factors 171 particularly relevant for adults with ADHD because executive dysfunction, even when well-managed, makes these individuals susceptible to backsliding when adaptive habits are disrupted. A long-range view of management of ADHD, similar to that for managing diabetes, is fostered for the ongoing use of coping skills. As we have emphasized throughout this volume, even when they are committed to their treatment goals, it is a difficult challenge for adults with ADHD to implement the requisite steps at the point of performance due to a combination of executive dysfunction, motivational deficits, overlearned avoidant habits, and learned pessimism. Our emphasis on motivational issues and the integration of implementation intention strategies (Gawrilow & Gollwitzer, 2008) also overlaps nicely with and draws from the literature on motivational enhancement approaches that have been used in the treatment of marijuana abuse (Miller, 2000; Riggs, 2003). Motivational enhancement (Miller, 2000) does not involve confronting denial, but rather empathizing with the patient’s outlook. In doing so, the clinician gains leverage in pointing out any disconnects between the patient’s current and desired circumstances. Moreover, these difficulties with change and the seeming illogic between one’s goals and behavior is normalized as a standard part of the change process, thereby dealing with resistance by acknowledging it and “rolling with it” rather than arguing against it. The aim is to support the patient’s agency to engage in the change process wherever they may be in that process. Various implementation strategies have been discussed in previous sections that are easily adopted as motivational enhancers within CBT. Recognizing automatic thoughts and other reactions to situations and developing alternatives through the eyes of a personal “defense attorney” is a useful exercise that offers a way to handle various choice points. Likewise, normalizing and accepting a degree of discomfort in the change process is an important emotional management skill that acknowledges that someone does not have to be “in the mood” in order to engage in a challenging but valued task. At the same time, escape behaviors and various behavioral scripts can be made explicit in order to provide a patient with more options for handling any given situation. Imple- mentation strategies can be used to further anticipate and address foreseeable barriers through explicit coping plans. In the spirit of motivational enhancement and respecting personal agency, some patients may still choose to not change, at least not yet. How- ever, these sorts of interventions will more often help ambivalent patients enter into the change process.

Downloaded by [New York University] at 12:14 14 August 2016 Treatment Complicating Behaviors The term therapy-interfering behaviors covers a range of behaviors that disrupt treatment, including actions (or inactions) that interfere with the delivery of treatment (e.g., poor attendance, resistance, self-harm), acting out (e.g., criticism, hostility), and other difficult behaviors that are factors in clinician burnout (e.g., boundary crossing, nonadherence to administrative policies) (Linehan, 1993). We were originally going to use the conventional term therapy-interfering behaviors as the section title but instead settled on the above title to describe behaviors that impede therapeutic progress in patients with ADHD. Moreover, these behaviors are not the sorts that are directly linked to symptoms of ADHD, such as missing appointments because of disorganization or forgetfulness. 172 Complicating Factors Rather, these behaviors can be considered compensatory strategies or attempts to deal with ADHD that are ultimately self-defeating and disrupt treatment.

Lying Lying, either by omission or commission, is a behavior that is deleterious to treatment outcomes and undermines the therapeutic alliance. Of course, mental health professionals commonly encounter distortions of information and rationalizations for behaviors in their daily clinical work. For our purposes, however, we will define lying as intentionally withholding information or providing misinformation about issues relevant to the treatment plan. That is, there is a difference between someone who said they devoted 2 hours to working on a project, but it turns out that a sizable chunk of that time was spent on distracting activities, versus someone making the same claim who, in fact, spent that time out socializing with friends. In particular, we have increasingly encountered college students who have lied about class attendance or progress on assignments, having not attended a class at all during a semester or not looked at a major assignment, only later to learn of the deceit when the student faces some sort of academic crisis as a consequence. Similarly, some adults with ADHD in treatment for occupational problems or unemployment have disclosed after the fact that they actually had not attended business meetings, job interviews, or worked on projects as they had originally claimed. Disclosures of substance use, excessive technology, relationship infidelity, and other behaviors that run counter to the stated goals for treatment may come to light during treatment, particularly when problems arise as a consequence of these behaviors. We view these examples of lying or nondisclosure as different from situations in which patients with ADHD do not follow through on therapeutic tasks but admit so, such as a student who developed a study plan for an exam during a CBT session but in the following session admitted he fell into his old pattern of pulling an all-nighter, instead. Or a situation in which a person uses deception in another area of life but addresses the issue in session, such as a worker saying that she called out sick in order to avoid a presentation for which she had waited too long to organize her materials and felt unprepared. These sorts of coping difficulties are central to the treatment of ADHD and in the two examples listed above, the issues can be addressed in sessions in a timely manner. Nondisclosure of clinically relevant information, such as significant sources of distraction (e.g., pornography use), substance use, or self-initiated changes in prescribed medi-

Downloaded by [New York University] at 12:14 14 August 2016 cation usage (including overuse) denies clinicians important treatment information. In some cases, patients disclose actions after the fact in order to address the behaviors that, if discovered outside the confidentiality of the doctor-patient relationship, would have grave legal or academic consequences, not to mention potential medical consequences in cases of medication misuse. The end result is that the misinformation in treatment must be addressed in terms of the treatment alliance in CBT as well as dealing with the crisis that likely necessitates the disclosure or discovery of the deceit and its aftermath. The treatment alliance in clinical psychology and psychiatry is designed to be different than other interpersonal relationships. There are special professional and legal protec- tions afforded this relationship (e.g., confidentiality, privileged communication) to foster safety and openness. The treatment relationship is a defined professional relationship Complicating Factors 173 with a unidirectional focus on improving a patient’s well-being through the use of interventions. Hence, a first step in dealing with lying is acknowledging the various effects of this event when the truth (and lie) has come to light. In cases in which the patient reveals the deception, appreciation can be expressed for the disclosure and acknowledgement can be made of the difficulty in doing so. In cases in which accurate information has come to light through other sources or due to the consequences of the deceit, expressions of empathy for the patient’s stress and plight can be used to set the stage for any immediate problem management that is required. However, it is clearly stated that there will have to be a discussion of the impact of the deception on the treatment alliance and approach the issue in the spirit of improving communication and fostering collaboration. Nondisclosure of information can reflect a patient’s vulnerability or embarrassment around a behavior (e.g., pornography use) or misjudgment (e.g., missing the entire first week of classes) by dealing with these feelings through avoidance. The alliance in treatment offers a forum for understanding not only what happened, but also how it happened. Our experience with adults with ADHD is that there is usually a build-up of minor indiscretions that individually could have been managed without incident, but this requires adequate error detection and the ability to readily disengage from a course of action, which are facets of intact executive functioning. Eventually, an initial trans- gression is managed poorly, which in turn kicks off a cascade of missteps that amass into a serious and negative outcome. These conceptualizations provide explanations for what contributes to problematic behaviors leading to the deception in order to intervene effectively. But they do not excuse these behaviors, nor should it mean that the person will avoid the consequences of his or her actions. Regardless of how the information comes to light, a sense of collaboration during the discussion of the lying/nondisclosure should be communicated. As was mentioned above, the forum of CBT allows these sorts of misjudgments to be reviewed in a nonjudgmental and therapeutic manner. This approach also sets the stage to repair the alliance, acknowledging that CBT and other therapies rely on and require reasonable accuracy of information without willful deceit. Similar to lack of follow-through or other difficulties commonly encountered in CBT for adult ADHD, the sequence of events leading up to and throughout the maintenance of the deception are reverse engineered using a functional analysis framework. In many cases, the review is straightforward, easily addressed and integrated into treatment, such as an individual whose excessive “computer use” late at night is now understood as com-

Downloaded by [New York University] at 12:14 14 August 2016 pulsive pornography use that is threatening a marriage; or a college student with ADHD starts taking an extra or higher dose of a prescribed stimulant because the lower dose does not seem to be effective. In the latter case, psycho-education can be used to inform the student of a procedure for consulting with a prescribing physician about dosing changes; in the former case, a nonjudgmental functional analysis of the pornography use can be performed to identify what perceived benefits the patient achieves through these behaviors as well as their drawbacks. An informed decision can be made about pursuing other, less problematic means for achieving these same benefits. For example, Philip, a college student with ADHD was on academic leave from his college in order to obtain treatment for ADHD. As part of his coping plan, he was enrolled in two courses at a local community college near where he lived with his parents. Behaviors 174 Complicating Factors related to class attendance and follow-through on assignments were central to Philip’s treatment plan. However, it came to light during the final week of the summer term that he had not attended one of the courses at all. He apparently spent time on campus or otherwise busied himself until returning home at the expected time, the presumption being that he had attended class. Philip discussed assignments and plans for this class in his CBT sessions, keeping up the appearance that he was attending class. His parents were understandably upset and wondered about his readiness to return to college. Regarding the treatment alliance, Philip’s therapist inquired as to whether there were any factors in sessions or about the therapist or his style that may have inhibited him from sharing the fact he had not attended class earlier in the semester. Philip stated that he felt comfortable with the therapist; in fact, that feeling made him feel worse about his deception and contributed to his cover-up in the hope to avoid being viewed in a negative way by the therapist. It is most often the case that deception by patients with ADHD does not start out as an intentional act, instead being driven by attempts to avoid being viewed negatively by others for mistakes and difficulties associated with ADHD. The effects of a misjudgment are exponentially magnified as the individual tries to rectify or cover up the situation without being found out. In some situations, the person may be able to pull it off, but usually the situation magnifies and spirals out of control. In particular, patients describe some familiar combination of guilt, shame, and embarrassment, and the situation becomes further evidence of their being “bad,” “unworthy,” or “broken.” Philip was asked about his expectation for how the therapist would react when he learned about his situation. He stated he was pretty sure the therapist would be even- tempered and handle it in the manner that it was. However, he added that “You have to react that way because you’re a therapist. I just know that you must be disappointed in me and that I wasted your time.” The therapist responded that he wished Philip had brought up the situation earlier because it would have given them a chance to work together to salvage the class and because it must have been scary and stressful for Philip to carry around his secret. However, the therapist also pointed out that Philip seemed to have a negative expectation about how others saw him as a person—the view that he is “only as good as what he can produce.” This led to a discussion of the effects of his different beliefs: “I’m only as good as what I can produce” and “I cannot keep up (i.e., produce) as well as other people” (therefore, “I am inadequate.”). The therapist offered a final, positive reframe that in future situations Philip could use the impulse to escape a problem through deceit as a signal to think through how he could face it directly and proactively.

Downloaded by [New York University] at 12:14 14 August 2016 Regarding the reverse engineering of the summer term, Philip said that while on his way to the first class, he learned from a friend in the class that there had been an assignment posted online that was to be submitted at the first class. Philip had assumed that the first class would be an introductory lecture, and he had not yet purchased the textbook that was needed for the assignment. He worried about starting off with a missed assignment and felt embarrassed that he had not prepared adequately for the first class, an inauspicious start to his academic leave. Philip quickly decided to skip the first class, buy the textbook, complete the assignment, and contact the instructor with some sort of excuse for his absence. On his way to the bookstore, however, Philip ran into some friends, and “before (he) knew it,” he missed his chance to get the book because he did not know that the campus Complicating Factors 175 bookstore closed early during summer sessions. There were a series of similar rationalizations and misjudgments that further contributed to his slowly mounting problem as well as his escalating anxiety about his plight. He recognized that he would eventually face the consequences of his behavior but he justified ongoing avoidance based on unrealistic plans (i.e., “magical thinking”) for how he might be able to get out of his conundrum. In Philip’s case, as with many adults with ADHD, there was a desire to follow through with a plan but that desire was undermined by competing anxiety and embarrassment activated by coping difficulties associated with executive dysfunction. He responded well to the stability of the therapeutic alliance and used treatment to truly learn and grow from difficult situation. Some adults, on the other hand, exhibit oppositional attitudes and behaviors in treatment that may contribute to an air of hostility and a continuous pushing of boundaries in treatment.

Adult Oppositional Behavior Oppositional Defiant Disorder (ODD) is a common comorbidity in children with ADHD that is characterized by defiance, argumentativeness, and angry hostility toward others. In fact, the recognition of the role of deficient emotional self-regulation (DESR) in ADHD may help explain the overlap with ODD (Barkley, 2010). That is, ODD is a syndrome that results from a combination of excessive emotional reactivity and a permissive environment in which oppositional behaviors are insidiously reinforced, leading to further disinhibition and defiance (Patterson, Reid, & Dishion, 1992). Similar to the antiquated notions that children with ADHD will “grow out of it,” considering the pairing of ADHD and ODD in many childhood cases, this comorbidity pattern may persist into adulthood. However, it will manifest itself differently in adults and represents a particular clinical challenge. Clinic-referred adults with a developmental trajectory of ODD that developed into more severe conduct problems and antisocial behaviors often present with coexisting issues, such as substance abuse or legal problems; however, individuals in outpatient treatment with milder, though persistent, oppositional patterns present as argumentative, as passive-aggressive, or as having a tendency to externalize blame for their difficulties. In fact, these individuals may have been able to use these qualities to obtain some measure of success in some domains of life, but face difficulties in other domains in which these qualities are less adaptive. In some cases, the oppositional adult with ADHD presents as someone who is ambivalent about the need for change, if not completely resistant to the notion. Motivational

Downloaded by [New York University] at 12:14 14 August 2016 enhancement strategies hold the best hope for identifying domains of functioning in which the patient may be interested in making changes or at least having different experiences, including those that might have led to the referral. Without colluding with the oppositional behaviors, the clinician can frame potential treatment objectives in terms that might appeal to the patient (e.g., “So, it sounds as though life would be easier for you if you could keep your boss ‘off your back.’ Assuming he is not going to change, what are steps you can take to make that happen?”). The clinical truth of the matter, however, is that oppositional adults as a group are liable to decline treatment or drop out after only a few sessions. A more vexing situation is that in which someone regularly attends treatment sessions but exhibits oppositional attitudes or active resistance to change. Of course, resistance is ubiquitous in all forms of psychotherapy, including CBT approaches (Newman, 2002). It 176 Complicating Factors is useful to take a specific situation that represents a source of frustration for the patient and use Socratic questioning to reverse engineer the various facts of it in order to uncover the source of the resistance. Although useful in any CBT session, the use of a summary of information about the situation being discussed is an intervention that allows the therapist to gently confront the oppositional patient (e.g., “So, your boss gave everyone notice of the new attendance policy and rules for clocking in and out for each shift, no exceptions. You are angry because you found out that you have not qualified for the $50 bonus due to being late too often, which you acknowledge. Help me understand your rationale for why you should get the bonus, anyway.”). Similarly, a downward arrow (Burns, 1980) helps focus on an initial oppositional reaction (i.e., “I deserve the bonus for all I do at work once I’m there.”) in order to uncover underlying concerns (i.e., “They only notice things I do wrong and no one sees what I do well.”). This sort of exercise and conceptualization enhances collaboration and provides some therapeutic leverage for change or at least for raising insight about one’s reactions. An equally challenging situation is dealing with excessive externalization of difficulties and responsibility for change. While there may be reasonable academic, workplace, or other accommodations, understanding, and support (including financial) provided by others that are helpful to someone with ADHD, these supports cannot guarantee improvements, such as completing school, keeping a job, or other desired outcomes. Similarly, various treatments, including CBT and medications, offer strategies for managing symptoms and provide a degree of symptom improvement, but they cannot offer ironclad guarantees that all goals will be achieved in the manner someone desires. The issue of externalization in adult ADHD manifests itself as excessive blame placed on others for one’s circumstances. There are often cognitions related to “lack of fairness” and “magical thinking” that may come across as a sense of entitlement or narcissism. These patterns are expressed in attitudes that others should not place demands on the individual and should unquestioningly adjust to the stipulations of the person due to ADHD. On the one hand, there is a grain of truth in these outlooks, as adults with ADHD often experience undue criticism or difficulties from others’ lack of knowledge or recognition of ADHD. On the other hand, these attitudes run the risk of being self- defeating when they are taken to the extreme. That is, individuals may hold unrealistic expectations for desired outcomes and thereby give up on taking proactive coping steps and by placing inordinate responsibility on others for one’s well-being. From a cognitive modification and problem management perspective, the challenge is to modify “all-or-nothing” thoughts and expand coping options. There might be a

Downloaded by [New York University] at 12:14 14 August 2016 degree of cognitive inflexibility at play, magnified by strong emotions, most often anger. It is useful to draw on positive therapeutic alliance to employ motivational enhancement strategies to address the pattern of externalization. Empathizing (without colluding) with the patient’s frustration and using disarming techniques (e.g., “You’re right—many things are harder for someone with ADHD. It must seem unfair that you have to work twice as hard as your coworker to get the same results.”) helps to set the stage for refocus- ing on managing the situation (e.g., “Do you think if you first used some of the coping steps we discussed in here that they might help you get started on the project? If you find out that they do not, then you can go back to your boss and make another case for being allowed to do your work in an empty office rather than in your open cubicle.”). Problem management strategies can be used to identify in specific behavioral terms the patient’s Complicating Factors 177 situation as well as action steps the individual can perform, including the subtle but critical difference between the communication skills of assertively and effectively asking for help, and the less-than-optimal strategy of always making demands on others. In most cases, externalization is a manifestation of anger and frustration on the part of the individual with ADHD associated with an attitude of being owed “reparations” for past frustrations or wrongs. The process of securing external accommodations, even when justified, may also reflect magical thinking—“if I can get X, then that will take care of all my problems and it will be easy going.” Cognitive interventions will repeatedly present the implications of externalization to the individual and the reality that these accommodations may not be available—a form of reality testing. Simply restating and summarizing the requests (or perhaps demands) the patient is making of others as well as the expectations for what these will achieve may help the patient gain a more accurate perspective. In turn, helping the patient develop a sense of acceptance of the situation “as is” and tolerating frustration while still staying committed to a valued behavioral objective is an effective use of acceptance-commitment strategies aimed at making changes. The development of alternative, more realistic and personally valued options can then be explored and the relative costs and benefits of different scenarios assessed. Past grudges can be acknowledged and processed, but the coping task returns to a here-and-now focus. Oppositional patients, particularly when they exhibit a combination of resistance to coping strategies and the externalization of blame, represent an extremely challenging subset of adults with ADHD. In addition to using the case conceptualization to understand the interaction of ADHD, DESR, and oppositional behaviors to understand the patient’s clinical presentation, this conceptualization also helps the clinician to maintain empathy for and understanding of the patient in the face of what can be challenging behaviors so as to focus on providing good treatment despite these obstacles.

Physical and Medical Well-Being Considering the negative impact of executive dysfunction on the organization and monitoring of behavior across time, it makes sense that adults with ADHD have greater difficulties than non-ADHD adults with matters requiring persistence, such as saving money for retirement or completing a home improvement project without a deadline. It also stands to reason that adults with ADHD have greater difficulties maintaining healthy lifestyle behaviors and habits that promote overall well-being, such as exercise and a healthy diet. These difficulties also extend to the maintenance of regular and rec-

Downloaded by [New York University] at 12:14 14 August 2016 ommended health checks, including physical examinations, dental visits, and simply tracking one’s sense of physical well-being to identify health changes that may warrant obtaining a medical consultation. There is some evidence to suggest that adults with ADHD may be at greater risk for obesity and heart disease due to sedentary lifestyle and poor health habits (Barkley, Mur- phy, & Fischer, 2008; Brook, Brook, Zhang, Seltzer, & Finch, 2013; Cortese, Faraone, Bernardi, Wang, & Blanco, 2013; Nigg, 2013). Moreover, medical conditions requiring ongoing diligence to monitor and manage, such as diabetes, can be particularly challenging for adults with ADHD to handle. Finally, there are adult developmental factors that may affect ADHD management, including menstrual cycles, pregnancy, and menopause for women, and normative cognitive decline for middle age and older adults. 178 Complicating Factors For women with ADHD, there are anecdotal accounts of worsening symptoms during the days leading up to menstruation and during perimenopause and menopause, although there is not yet a strong evidence base from which to design management strategies. It is particularly in the domain of attention symptoms that women with ADHD often encounter increased difficulties, which can be magnified by the emotional lability that accompanies these stages. Personalized medication adjustments can be recommended to manage increased inattention at these junctures. Medication options also include the use and/or adjustment of antidepressants to treat mood lability or depressive symptoms. Similarly, a commitment to the use of coping strategies during these times is also helpful. For adults with ADHD with diagnosed medical or health conditions requiring persistent management, these health-related behaviors are central targets for psychosocial intervention. While this issue has not been a common one in our practice, we assume that the prevalence of ADHD occurs at least at the same rate in these medically vulnerable populations as it does in the general population. In fact, a hypothesis to be examined is that ADHD prevalence rates among these populations might be somewhat higher than general population rates because poor executive functioning (e.g., poor self- monitoring, poor health maintenance) put individuals at risk for the development of some conditions, such as adult onset diabetes, high cholesterol, etc. There are also less dramatic health issues that play an important role in overall health, well-being, and management of ADHD, such as food sensitivities, allergies, caffeine use, or simply taking ADHD medications on a consistent basis. There are many preventative behaviors that can be addressed in treatment, such as safe-sex practices, substance use patterns, and patients’ health promoting strategies (i.e., diet, exercise, and sleep). Health issues within CBT for adult ADHD are treated as are other treatment goal by operationalizing them in behavioral terms. As with other behavioral targets, the use of a Daily Planner to organize a health routine is an important starting point, such as times to take prescribed medications or scheduling medical visits. Barriers to follow-through and the use of motivational enhancement and implementation strategies (both models having been originally developed, in part, to increase compliance with follow-through with health care recommendations) can help establish adaptive health habits, such as compliance with a medication regimen, taking insulin, or following through with prescribed diet and exercise regimen to reduce cholesterol levels. When the behavioral target involves the administration of a medication, or the availability of a use-as-needed device, such as inhaler or contraceptive, it is best if a location- based routine can be developed. For example, individuals who take a morning dose of a

Downloaded by [New York University] at 12:14 14 August 2016 stimulant medication can keep the pills and a bottle of water on a nightstand by their bed or in the nearby bathroom. Prospective problem management involves predicting likely exceptions to this routine, such as on weekends, whether the patient may awaken in a different location (i.e., romantic partner’s apartment, frequent business travel), etc. Plans for these scenarios can be developed (e.g., keep extra medications at partner’s apartment). Even in cases in which an adult with ADHD does not have a specific medical condition, good health habits related to exercise and sleep routines are relevant for treatment insofar as they support overall well-being. In fact, even if not providing direct therapeutic benefits, some good health habits, particularly sleep and exercise, may set the stage for improved response to medication and psychosocial treatment, although this is still Complicating Factors 179 conjecture. The next sections will focus on issues of exercise and sleep that are particularly relevant for adults with ADHD.

Exercise Health promoting behaviors, such as exercise, are handled in a similar fashion to other positive habits that patients wish to establish, such as studying. There is the planning issue of when the task will occur and how much time will be devoted to it. As with other tasks, it is important to encourage realistic expectations and planning. Clinicians will often find themselves helping patients guard against either underestimating the time commitment (e.g., “If I rush home after work and get on the treadmill right away, I can probably squeeze in 15 minutes before picking up my daughter from practice.”) and overestimating the time commitment (e.g., “I will not get the results I want unless I go to the gym two hours, every single day.”). The goal is to “lower the bar” in order to make the commitment brief enough that the person can get engaged in it, yet sufficient enough that it has a positive impact. The planning issues are intertwined with the particular definition of the health behavior. Exercise may be defined as taking a walk during a lunch hour, or as taking a specific time-based (30 minutes) or task-based (3 miles) run after work. A starting point could be as simple as parking one’s car in a space farthest from the office door and walking up the stairs rather than using the elevator every day at work. As with other tasks, a primary focus is “getting started” on the exercise task, such as getting into the car to go to the gym or changing into running clothes (instead of turning on the television) immediately after work as a means for defining a manageable engagement task which greatly increases the likelihood of follow-through. Predicting difficulties is a useful way to increase the likelihood of persistence over time, such as developing winter exercise plans for the man who enjoys bike riding outdoors, or at least anticipating how a plan will have to be adapted to different situations, such as adjusting a workout if a gym is particularly crowded or a particular exercise machine is not working.

Sleep An important health issue to explicitly review with each adult ADHD patient is that of sleep. It is absolutely essential for adults with ADHD to establish healthy sleep patterns. Sleep issues should be reviewed as part of the initial evaluation and should be monitored

Downloaded by [New York University] at 12:14 14 August 2016 throughout treatment. For patients with poor or at least questionable sleep habits, time in session is spent defining specific sleep plans, including the process of preparing for sleep, getting into bed, and having an adequate wake-up time in the morning. Without a plan for sleep, adults with ADHD are at risk for staying up late despite feeling tired. Col- lege students are already at risk for unhealthy sleep habits, and students with ADHD face even greater difficulties with self-regulation and negative effects associated with fatigue. A common scenario is that the adult with ADHD does not have a primary sleep onset disorder but, instead, reports procrastinating about sleep despite feeling tired. Patients report difficulties disengaging from an enjoyable, though unimportant task, such as playing a video game, watching television, or perusing a social networking site. This pattern reflects perseveration, which is the inability to switch tasks, particularly when the 180 Complicating Factors current one is no longer productive or adaptive. When asked, the person admits feeling tired but has trouble stopping the task at hand. Inquiry may reveal the presence of negative thoughts about sleep (e.g., “It’s boring. I just lay there with my mind running. When I wake up I’ll have to face another day of work.”) that are the targets for cognitive modification and implementation plans. In most cases even cursory motivational enhancement questions yield adaptive outlooks about and the personal relevance of sleep (e.g., “I know I feel better when I am rested. My day would be easier if I was better rested.”), though the task is to improve the implementation of these plans. A specific sleep routine or a “sleep script” is outlined. To illustrate the importance of such a plan to promote sleep, the common bedtime routine used with young children is discussed to illustrate some main points. That is, young children are often taught that there is a period defined as the start of quiet time during which there are no physically or emotionally stimulating activities, such as running around, etc. The child may read or have a small snack during this time. The child often changes into pajamas and has some sort of presleep ritual composed of a sequence of behaviors that serve as a priming for sleep, such as brushing teeth, putting toys away, getting clothes ready for the next day, etc. Finally, the child gets into bed and may read, have a story read to him or her, and eventually the lights are turned out and the child goes to sleep. The notion of a similar behavioral plan that promotes sleep helps adults with ADHD to consider an alternative behavioral script that will promote good sleep habits to counter the “procrastinate on sleep” script. Most often it is helpful to have a time-based plan that involves a schedule of tasks, such as “get off computer at 10 p.m., choose clothes for next day,” etc. Implementation strategies are used to anticipate potential vulnerabilities for violating these plans and responses are rehearsed. Individuals who describe difficulties “turning off” their brains are encouraged to read in bed, preferably not using an electronic device due to research indicating the lighting they use interferes with melatonin production (Wood, Rea, Plitnick, & Figueiro, 2013). Various gadgets also present temptations to get engaged with online activities that could interfere with sleep. Reading material is ideally something that is very familiar or at least nonstimulating for the individual to decrease the likelihood of getting too engrossed in it. Old magazines, a book the person has already read several times, etc. may help the individual relax and fall asleep. There may be special components of the “sleep script” relevant for an individual, such as taking a nighttime dose of a prescribed medication or use of a CPAP (continuous positive airway pressure) machine for sleep apnea that are included in the plan.

Downloaded by [New York University] at 12:14 14 August 2016 In addition to being a distraction from sleep, various communication and gaming technologies also run the risk of taking up time away from exercise and other health promoting behaviors. The goal is to strike a healthy balance in one’s life. The next section focuses on helping adults with ADHD develop a balanced approach to handling technology in everyday life.

Dealing With Technology The explosion of technology and its accessibility and role in daily life over the past few decades or so has been remarkable. There are ripple effects in all areas of life and, for the most part, these technologies have been a positive development. Given their ubiquitous Complicating Factors 181 presence in our society, we are all discovering new ways to integrate these technologies, such as in education, healthcare, etc. in a more balanced fashion. However, for adults with ADHD, a group of individuals who are at increased risk for distraction and for pursuing short-term gratification at the expense of long-range plans, technology represents a unique and daunting challenge. The task for adults with ADHD is to develop a healthy relationship with technology. We use the metaphor of managing caffeine intake (or any sort of food sensitivity or allergy) to illustrate the approach to dealing with technology—in small doses, at the right times, caffeine can be a performance enhancer or a salient reward, such as a cup of coffee with a friend; on the other hand, when taken too late in the day caffeine interferes with sleep or, if taken to excess, caffeine interferes with performance, may result in caffeine intoxication, or can exacer- bate health problems. Likewise, the judicious use of technology plays a central role in coping with ADHD (e.g., organizational tool), provides a source of reinforcement for task completion, but also may be a source of distraction and procrastination. Hence, technology is a good servant but a poor master. The first step in striking a healthy relationship with technology is helping a patient with ADHD recognize and increase self-monitoring of technology use and its role in functioning. Early sessions in which the Daily Planner is used to schedule and track one’s activities and use of time may yield important information about technology use. Indi- viduals often report staying up late on the computer or spending excessive blocks of time devoted to unintentional television viewing, where the individual sat down in front of the television and “ended up” watching it for longer than was intended (which is differentiated from an intentional plan to watch a program). The situation is complicated by the fact that the very notion of watching “television” is increasingly done on computers and other electronic devices, and programs can be accessed and viewed at one’s conve- nience. Moreover, when watching a series using some entertainment services, there is little, if any, delay between the end of one episode and the beginning of the next one, which represents a supreme challenge to impulse control. These developments are a blessing for adults with ADHD because there is greater flexibility for engineering one’s schedule and using entertainment as a source of reinforcement; these developments also are a curse for adults with ADHD for the same reason—this flexibility means that they always have access to a source of compelling distractions that are difficult to manage. Although self-monitoring is challenging for individuals who suffer from executive dysfunction, the notion that technology can either be productive or unproductive helps individuals with ADHD be more likely to “catch themselves” in situations in which they are

Downloaded by [New York University] at 12:14 14 August 2016 engaged in unproductive technology use. Even if a patient reports, “I knew that I should have been working on my job search, but I went on Facebook anyway and I knew what I was doing as I did it,” this awareness represents progress inasmuch as it provides a template for how a patient “does not do things” and provides leverage for change. As with other habits, technology use is agreed upon as a behavioral target. It is a somewhat more complex target because there is a subtle, though definitive line between using technology as a tool to perform priority tasks, such as academic work or a job search, and as a distraction, which is always “just a click away.” We start with some form of motivational enhancement in order to establish the commitment of the patient to focus on modifying this behavior. Drawing on implementation strategies, we then identify specific examples of vulnerability during the day in order to “start small” and to 182 Complicating Factors develop plans for these “pivot points,” such as taking steps to get offline in order to get to sleep. The typical behavioral script for problematic technology use is reviewed to gain an understanding of the salient cognitions, emotions, and behavioral steps that maintain it. An alternative behavioral script for adaptive technology use (e.g., as positive reinforcement for task completion) is developed, including implementation plans for handling various barriers to following the new plan. It is common for technology use to serve as a quick “escape behavior” when facing difficult or boring work. The rationalization cognition is, “I just have to check one thing before I get to work” or “I will just play one game and then I will be ‘in the mood’ to work.” These cognitions are usually associated with reports of some degree of visceral, emotional discomfort associated with the priority task. Even when the discomfort is mild, it is sufficient to trigger avoidance. Hence, task engagement requires a synthesis of mindful acceptance strategies for tolerating task-related distress (e.g., “I can notice how I feel, accept this feeling, and still work on my paper.”), adaptive cognitions (e.g., “This is uncomfortable but tolerable; I’ll feel better having worked on the paper, even if I only do a little bit.”), and behavioral engagement steps to make the task manageable (e.g., “I will open the file and read the last paragraph I wrote.”). Taken together, these strategies support an adaptive behavioral script that can be positively reinforced by task engagement (rather than avoidance being negatively reinforced). That is, patients often underestimate the positive feelings associated with getting things done or at least making progress on them. Perhaps as important as being able to engage in a particular task is that this format provides adults with ADHD a template or scaffolding for handling technology. It also enables them to understand and normalize setbacks in order to maintain resilience rather than simply giving up.

Professionals’ Reactions to ADHD Patients As one of our professional colleagues said to us after his first clinical experience with adult ADHD, “I never realized how hard life is for adults with ADHD.” Many of the day- to-day tasks and obligations of adult life that non-ADHD adults handle effectively with relatively little effort can be very difficult and time-consuming for adults with ADHD. Likewise, treatment itself makes demands on one’s executive functioning, such as maintaining daily medication regimens, attending regular CBT sessions, being on time for appointments, and devoting time and effort to implementing new coping strategies. While clinicians’ attention is rightly focused on patients’ needs and on helping them to

Downloaded by [New York University] at 12:14 14 August 2016 make changes in their lives, it is important for helping professionals to identify their reactions to patients insofar as they may negatively affect the course of treatment. In some isolated cases, a clinician’s reaction to a patient with adult ADHD reflects a developmental or psychological issue that is idiosyncratic to the clinician. That is, the response represents a true countertransference or a distorted reaction by the therapist toward the patient. For example, a therapist was irritated by a disorganized middle-aged female patient who repeatedly arrived late to sessions. The therapist’s anger was associated with his personal issues associated with his unreliable mother whom he felt blamed him for her shortcomings. In such cases, the onus is on clinicians to recognize these patterns and to adjust their demeanor with patients, often while seeking regular consultations with a professional colleague to maintain “quality control.” Complicating Factors 183 On the other hand, a more common scenario is that a clinician feels annoyance at a patient’s repeated lateness to session that reflects the type of response that most people, including others in the patient’s life, have when facing the same situation. While a clinician familiar with ADHD can be particularly empathic to how ADHD contributes to lateness and other coping difficulties, the unique characteristics of the treatment alliance, as discussed earlier, provide a setting in which to recognize and address these patterns in a therapeutic way. Handled poorly, though, therapists’ negative reactions run the risk of replicating embarrassing and invalidating exchanges patients with ADHD have had with other influential people in their lives. Thus, clinicians’ thoughts, such as, “She must not take me or treatment seriously” or behaviors, such as continuing to work on administrative tasks at the time of the patient’s appointment, assuming she will be late and then making her wait while the therapist reaches a good stopping point provide some hints of the types of negative reactions the patient may encounter in other relationships in her life. Feelings of frustration or boredom toward ADHD patients also provide useful signals for the therapist to pay attention to these reactions and to realize they may be losing sight of the difficulties their patients with ADHD face in their daily lives. The purpose of this topic is not to admonish clinicians for these reactions—they are normative and will occur. Moreover, many patients with ADHD will be attuned to signs of such frustration and may harbor worries about their therapists’ reactions to them (e.g., “My therapist must dread me coming in here when I still have not yet gotten a Daily Planner.”). Rather, similar to providing patients with a framework for understanding how they “do not do things” in order to develop an adaptive framework, our goal is to recognize these reactions in order for clinicians to develop adaptive ways to deal with them. These reactions can be useful for treatment because, as was indicated above, others in the patient’s life likely have similar reactions and may react by simply withdrawing from the patient over time. CBT sessions address these potential pitfalls by putting the issues on the table as therapeutic agenda items. It is a useful practice to periodically take stock of CBT and assess how well it is working and whether any adjustments are required. To this end, the therapist can use this opportunity to observe the ongoing difficulty the patient has, for example, arriving to session on time and can inquire as to whether she faces the same problem arriving for other meetings. In some cases, it may be a problem unique to the treatment appointments (e.g., “I was on time but could not find parking.”), though most often the problem comes up in other settings, too. Hence, a problem management approach can be useful, using the issue as it affects the session in such a way as to prac-

Downloaded by [New York University] at 12:14 14 August 2016 tice new skills. In most cases, the sort of “gentle confrontation” or refreshing a treatment goal as described above provides a face-saving and collaborative way to address the issue with the patient. Rather than avoiding this issue, this approach acknowledges that more work needs to done—collaboratively—on a particular goal. In fact, the therapist can make a statement about what he or she can contribute to the process (e.g., “I can do a better job making sure you leave here with a clear behavioral plan for the homework.”) to model the notion that problems are considered behaviors that can be changed rather than immutable character flaws. In most cases, this sort of discussion often rekindles and improves the focus on the therapeutic objective whereas it would likely not be faced in real-world relationships. 184 Complicating Factors A small subgroup of patients will be somewhat more resistant to change, perhaps externalizing responsibility (e.g., “How can you expect people to be on time when there is not enough parking. I should not have to pay for the full session if it is not my fault. Other offices validate tickets for the parking garage. Why doesn’t yours?”). Again, reviewing examples of similar difficulties in other situations as a rationale for focusing on the issue as well as the benefits for dealing with it (e.g., “If you arrive on time, you will get your full time in session.”) and drawbacks to ignoring it (e.g., “How does your boss react when you are late?”) help turn the issue into a therapeutic one. Similarly, identifying proactive steps the patient can take to handle situations helps them to employ coping strategies and hopefully build up interpersonal collateral (e.g., “Do you think your boss might be more forgiving of isolated lateness if you showed up on time for a week or two in a row?”). The purpose is for therapists to avoid feeling responsible for facing the natural frustrations of daily life and to help patients with ADHD adapt to and manage these situations and their associated frustrations. Of course, the patient is an independent, free-thinking adult who can make an informed decision and who may choose to accept the consequences associated with maintaining a behavior. In terms of clinician self-care and quality control, it is useful to monitor reactions to patients and to the common ADHD-related problems addressed in treatment. The clinician may have reactions to the typical functional difficulties and become frustrated as a result of overgeneralizations (e.g., “All I do is phone in prescriptions for people who wait until they run out of their pills,” or “We are still talking about how disorganized his office is but he still has not taken action to work on it.”). Just as we advise patients, clinicians must identify their distorted thoughts, review the evidence, and develop more balanced and helpful reactions. It is useful for the clinician to reflect on the predica- ments of individual patients and to focus on their unique circumstances. The focus on each real-world situation provides clinical information that helps the therapist get engaged in the situation at hand. Drawing on interventions we provide to our patients, clinicians can develop a specific behavioral script for addressing a challenging issue with a patient during the next meeting. The individualized case conceptualization framework within CBT for adult ADHD helps to further personalize the clinician’s understanding and management of an issue. With apologies to Tolstoy, it is useful to remember that organized people are all alike; every disorganized person is disorganized in his or her own way. On the other hand, clinicians also can be self-critical of their treatment, minimizing patients’ treatment gains (e.g., “She is using her planner and has been submitting her

Downloaded by [New York University] at 12:14 14 August 2016 work on time,”) and magnifying ongoing difficulties (e.g., “She still has problems getting to places on time.”). It is useful to have regular meetings with colleagues, particularly those familiar with treatment ADHD, in order to share cases and maintain perspective on the process of change in CBT. A standard feature of CBT is regular check-ins with patients to assess progress and the therapeutic process, which often yields useful information, including the benefits of treatment, new goals that may have arisen from this progress (e.g., “Now that I have gotten better at X, I want to focus on maintaining it.”), and possibilities for improvement (e.g., “I think our session agendas are too ambitious. Perhaps we can try focusing on one or, at most, two items”). Even when it is agreed upon that there are ways to improve treatment, the discussion makes it a collaborative endeavor and ideally focused on specific behaviors designed to bring about those behaviors, which Complicating Factors 185 is a hallmark of good problem management and which increases the likelihood of a positive outcome in CBT.

Signiﬁ cant Impairment The symptoms of ADHD lie at the extreme end of a continuum of adaptive executive functioning and motivation capacities, reflecting a degree of executive dysfunction and motivational deficits that falls significantly below that of individuals whose functioning falls in the middle or upper end of the continuum. Similarly, within the group of individuals diagnosed with ADHD, there is a continuum of severity of impairment, ranging from individuals who are generally functioning well in life but have mild, circumscribed problems (e.g., work performance) to those with severe impairment permeating throughout most domains of their lives. Clinicians who specialize in treating adults with ADHD recognize that they must adapt their typical therapeutic strategies because ADHD often interferes with patients’ attempts to get the most out of treatment. However, some individuals present for treatment with extreme symptoms that create significant impairments in daily life, such as unemployment, social isolation, financial problems, and, in some cases, legal problems. In addition to functional impairments in one’s life, these individuals likely have problems engaging in treatment, including medication management due to the severity of their executive dysfunction and motivational deficits. Adults with ADHD who present with this level of impairment have likely been under represented in clinical outcome studies of psychosocial treatments as well as in the population of adults with ADHD who seek out specialized treatment (cf. Kessler et al., 2006). We hypothesize that adults with ADHD with severe functional impairments are less likely to undergo a thorough evaluation that involves at least a screening for ADHD. Even in cases in which there is a history of ADHD, it is likely that there are more apparent coexisting psychiatric and/or substance use issues that may be targeted by treating professionals before underlying ADHD is recognized. In fairness, even though ADHD underlies these comorbid conditions, in some cases, the severity of these conditions requires that they be the main focus of treatment, such as ongoing substance dependence or a mood disorder with suicide risk. Even when adult ADHD is accurately identified and is a clinical priority, the patient may not have adequate insurance coverage, discretionary income, or time to devote to treatment. Finally and insidiously, ADHD symptoms and associated life impairments often interfere with the patient’s ability to

Downloaded by [New York University] at 12:14 14 August 2016 engage in and complete an adequate course of treatment, including organizing and maintaining pharmacotherapy appointments and prescriptions. Our discussion of severe impairment as a complicating factor is not meant to imply that there are “hopeless cases” or that clinicians should “give up.” Rather, we hope to encourage clinicians and patients to collaborate to set realistic expectations for treatment and to adapt interventions to “where the patient is at,” particularly when facing complex and numerous problems. In terms of starting treatment, it is important to identify the specific problems faced by patients in the different domains of their lives. Although there may be crises that require immediate attention and problem-management interventions, we view the approach of “starting small” and identifying the specific behavioral steps to achieve the 186 Complicating Factors desired outcome as being as important in cases of severe impairment as they are in any other case of adult ADHD. This step is not meant to imply that “big” problems should be ignored, but rather than an efficient entry point must be defined. In cases of multiple or complex problems, the first step involves unbundling and itemizing patients’ presenting issues into discrete problems. This step helps to sort out and triage the therapeutic issues, which is more manageable and less overwhelming than facing their sum total. That is not meant to say that the problems are not serious, but making problems specific and behavioral often helps disentangle the emotional reactions from what needs to be done to address the problem. In fact, this step often produces some emotional relief insofar as it represents a necessary exposure step in facing and dealing with the problems, highlighting the executive skills of organizing and sequencing information. In most cases of severe disruption in one’s life, such as loss of a job, forced academic leave, or significant financial or legal difficulties, adequate problem management involves having the patient initiate contact with someone who can help her or him manage the crisis at hand. For example, a student who missed two exams, has not attended subsequent classes, and who is now facing the reality of having fallen too far behind to be able to catch up on work will be advised to contact her academic advisor and professors (and her parents) to consider the available options for damage control. Similarly, a jobless professional whose savings are nearly depleted after a lengthy period of unemployment may have to broaden his job search to consider job options that heretofore would have been unthinkable prospects (at least to his mind). The option of looking into unemployment benefits to deal with mounting debt would also be raised at some point. Strong feelings of guilt, shame, or embarrassment felt by the adult with ADHD often fuel the impulse to avoid these outreach steps, despite the awareness that they need to be performed—which is the definition of procrastination (Steel, 2007). Adults with ADHD are at risk to react in an extreme manner, either taking no action to avoid further embarrassment about their problems, or acting rashly though inefficiently, often with a similar desire to handle a situation without the difficulty being made known to others. Either way, the reaction is an attempt to minimize facing distressing emotions rather than facing the stress of the issue in a measured, organized way to manage the problem. In cases of significant impairment, it is important to identify additional, outside con- sultants and services needed to address life crises. There can be the “magical” assumption that finding specialized treatment for ADHD will be what is needed to finally handle the assortment of crises. However, patients facing multiple and significant problems will

Downloaded by [New York University] at 12:14 14 August 2016 need help beyond what can be offered in individual CBT, even if session are scheduled more frequently in order to deal with the problems. Concurrent marital/couples therapy or family counseling should be recommended to deal with relationship problems. The patient can be encouraged to consult with a financial planner or bankruptcy/tax attorney to provide guidance for significant financial difficulties or a tax audit. Legal representation will be needed in cases of an arrest or pending divorce. Sometimes a clinician’s referral network is as valuable to a patient as her or his clinical acumen. Mental health clinicians are often on the front line of helping patients deal with life crises. The emergencies brought up in sessions often stem from the cascading effects of ADHD and various other problems on one’s life. The presence of ADHD also complicates efforts by affected individuals to manage random events and stressors in one’s life Complicating Factors 187 not connected with ADHD, such as recovering from damage to one’s home from a hur- ricane or dealing with an aging parent’s medical issues. Just as the patient may reach out for help from the clinician, the clinician will have to remember and communicate that he or she “cannot do it all” for the patient. However, the clinician can help the patient develop an action plan for finding additional therapeutic and/or support services with which to manage the problems at hand. Creating realistic expectations for treatment provides reality testing and allows for CBT sessions to be used more effectively. Finally, as was mentioned earlier, it is important for clinicians’ to monitor their own reactions to their patients struggles with severe impairment to avoid emotionally disengaging from them and “giving up” on the benefits treatment can provide. Instead, an attitude of unfailing resilience, empathic fortitude, and willingness to seek ways to manage problems—including reaching out to other professionals— increases the likelihood that treatment will continue to be helpful, even if it cannot solve all problems.

Medication-Related Complications While most patients find medications useful in reducing the symptoms of ADHD, there are predictable complications that may arise in the course of treatment. These include ambivalence about taking a medication, unrealistic expectations about the effects of medication, distorted beliefs about the meaning of taking a medication, nonadherence and misuse of medications, and adverse effects from medications. Clinicians should anticipate that any of these issues can become a focus of concern and, when they arise, should be approached in a straightforward, practical, problem-solving manner. Most adult patients express some degree of ambivalence about the necessity of taking a medication for their ADHD symptoms. This can take the form of an open acknowl- edgment of mixed feelings (“I really wish I didn’t have to take something to keep me focused on what I am doing . . .”) or of more indirect questioning (“Do you think I will need to take a medication for the rest of my life?”). In whatever way it is expressed, ambivalence is a completely normal and normative reaction to the situation. Few of us ever want to take medications, especially if we are expected to take them on a daily basis for an indeterminate length of time. Clinicians are on solid ground if they acknowledge the patient’s ambivalence as an understandable reaction, and if they offer support to an ongoing exploration of the patient’s negative reactions to being on medication. If the ambivalence is strong enough to lead the patient to resist taking the medication, it is best

Downloaded by [New York University] at 12:14 14 August 2016 to face this option as a positive choice on the patient’s part. This can take the form of the following reframe: “It looks like you’ve come to the conclusion that the medication is not worth taking. Perhaps this is a good time to take a break from it. You can always restart it in the future.” (Note: Clinicians without prescription privileges should encourage the patient to discuss medication adjustments with the prescriber and should be willing to consult with the prescriber with the expressed permission of the patient.) In a fair number of cases, patients are disappointed with the outcomes of a medication regimen they are taking. Their ADHD symptoms may not be remitting enough to make a difference in their lives, or they may be experiencing intolerable side effects. In cases of nonresponse, partial response, and/or serious adverse effects, it is best to advise the patient to discuss this with the prescriber. Modifications of the dose might be made 188 Complicating Factors to improve outcome or reduce side effects, or the medication regimen might be changed altogether. The important point to remember is that there are “different strokes for different folks,” and that it might take several medication trials before a reasonably effective and tolerable regimen is devised. Unrealistic hopes for a magic bullet to cure ADHD symptoms along with executive dysfunctions and motivational deficits are not uncommon among our patients. It is understandable that individuals who have spent their lives struggling with a disabling condition that was not diagnosed until adulthood would harbor a strong wish for an instant remedy for all their woes. Most people can see this as an idealistic wish, and can move beyond the stage of disappointment or disillusionment to a more realistic appraisal of what potential benefits might be derived from medication treatment. Occasionally, however, the disappointment is more profound, and the patient becomes embittered about their situation and the failure of modern medicine to provide any real relief. In these cases, it can be helpful to offer a supportive comment of concern and com- passion: “It must be very difficult for you to feel so hopeless about your situation. It would be wonderful if a cure for ADHD were available for you. But at the moment, we have imperfect tools to work with . . .” Allowing the patient to grieve their loss often leads to a renewed commitment to working within a more realistic framework. By contrast, it is not unusual for patients to respond to positive medication effects with statements like: “I am not sure that it’s really me that’s doing better or if it’s just the medication.” This is often based on uncertainty about the legitimacy of the diagnosis of ADHD and about its treatment with medication. It also reflects a moral sentiment that is rooted in broader cultural notions of “fairness”—namely, if taking a medication makes it easier to work and get things done, then it must be bad because it is “cheating.” Much of the controversy surrounding the increased use of stimulants on college campuses, for instance, evokes strong condemnations of stimulants as “cognitive steroids,” that is, as a way of cheating or gaming the system. This analogy to the use of performance-enhancing drugs in sports leads to excessive guilt on the part of patients who legitimately need and benefit from taking a medication for ADHD. The most effective way to handle this reaction first is to point out that it reflects a common cultural prejudice about ADHD, and that the patient will have to figure out a way of coming to terms with the actual reality of the disorder and its treatment. Secondly, it is useful to draw a metaphor between taking medication and wearing glasses. Glasses help to improve eyesight, but they don’t elimi- nate the need for an individual to exert some effort in order to read, write, etc. Similarly, the medication works to “sharpen one’s focus,” but it doesn’t do the work for the indi-

Downloaded by [New York University] at 12:14 14 August 2016 vidual. Eventually, most patients come to see this issue in a more balanced light. Nonadherence to medication treatment is very common in clinical practice. Pub- lished studies demonstrate that within 1 year of starting medications, roughly 50% of patients are still taking them, most likely due to lack of clinical response or side effects. There are wide methodological variations in these studies such that reported nonadherence rates ranged from 15–87% (Adler & Nierenberg, 2010; Ahmed & Aslani, 2013). The take home message, however, is that nondherence to medication treatment is very common in clinical practice. Even when patients report clear benefit from their medications, they often skip doses or stop taking the medication for extended periods of time. It is important to review the actual circumstances leading to nonadherence in order to address the problem head on. If the patient is simply “forgetting” to take the pill, it is Complicating Factors 189 helpful to set up a reminder system or to come up with a behavioral script and see if these strategies improve adherence. If the patient is not comfortable with the medications’ side effects, it is important to discuss ways to minimize their impact. At times, patients will skip doses because it allows them to be “more like themselves” (i.e., more spontaneous, less predictable, less constricted). This is particularly true of young adult patients who experience some stifling of personality from the medication, and/or who see that the effects of alcohol or other recreational substances are reduced when the patient takes the prescribed medication. A motivational interviewing approach to nonadherence is often helpful in getting the patient to weigh the pros and cons of medication use, and to look at their patterns of behavior. Once these are better identified, the patient can examine their motives for skipping doses and can take more responsibility for their behavior. It is also a good idea to encourage patients to discuss nonadherence with the prescriber. Misuse of stimulant medications includes taking inappropriate doses and/or at inappropriate times for nonclinical purposes such as staying up all night, cramming for examinations, suppressing appetite, etc. Abuse of stimulants refers to using them for recreational purposes (to induce euphoria), which is commonly done via snorting. Both of these sets of behaviors are serious risks to the patient’s health and should be handled by direct confrontation using a nonjudgmental and empathic approach. Finally, the occurrence of adverse effects from ADHD medications requires careful review of medication usage patterns and of the frequency, severity, and impact of the negative effects that the patient is encountering. Many of the side effects of stimulants are mild and transient in nature and subside after several weeks of usage. However, if potentially serious side effects are being reported (e.g., heart arrhythmias, shortness of breath, severe dizziness, fainting, mood swings, involuntary motor movements), they should call the prescriber immediately and make them aware of the situation. In the case of stimulants, it is safe to stop them immediately if any serious concerns are being raised. Other medications require a tapering process, although with atomoxetine and bupropion, this can be achieved relatively quickly (within a few days). Alpha2 adrenergic agonists can be slowly weaned over a few weeks, whereas SSRIs and SNRIs require a longer period of time to discontinue, and this should be done with great care to avoid triggering a discontinuation syndrome.

Chapter Summary

Downloaded by [New York University] at 12:14 14 August 2016 There are many issues associated with the core symptoms of adult ADHD that create complications for patients and clinicians. Just as there is great heterogeneity of symptoms and executive dysfunction profiles among adults who share the diagnosis of ADHD, there is a wide range of complexities that, in number and severity, add degrees of difficulty for patients and clinicians, alike. We have described some of the complicating factors we have observed in our clinical work in order to assist helping professionals to better manage them in treatment with their patients. By doing so, our experience is that these factors can most often be addressed collaboratively and effectively by patients and their clinicians in order to get the most out of treatment. Consequently, the focus of CBT then switches to maintaining treatment gains, which is discussed in the next chapter. 6 Maintenance and Follow-Up

There is no cure for Attention-Deficit/Hyperactivity Disorder (ADHD). ADHD is a neurodevelopmental syndrome requiring ongoing coping and maintenance in order to manage the myriad effects of executive dysfunction and motivational deficits on day-to-day life. Consequently, the conceptualization and treatment of ADHD can be thought of as operating from a habilitation model in which the goal is to adapt to and optimize one’s particular style of functioning (as opposed to a rehabilitation model, in which the goal is to restore a previous level of functioning). In the case of ADHD, this adaptation and optimization is achieved through the process of making desired coping behaviors automatic and routine (e.g., Solanto, 2011). The case could be made that through the process of habilitation, many patients go through a process of “abilitation” in which they also discover or uncover areas of competence and proficiency that had been obscured by ADHD and that they can cultivate to the benefit of their overall well- being and sense of self. Although finding a medication regimen that leads to symptom remission is the target of pharmacotherapy for adult ADHD, it is more difficult to draw the line defining when cognitive behavioral therapy (CBT) for adult ADHD is “finished.” In fact, even when patients reach a point at which their ADHD symptoms are considered to be effectively managed, ongoing maintenance of functional gains by continuing to implement coping strategies is an active and essential process, akin to ongoing exercise being required to maintain an achieved level of fitness. A stable, effective pharmacotherapy regimen also requires ongoing compliance in order to maintain its benefits as well as monitoring to determine if adjustments are needed. Thus, the long-range management of adult ADHD requires a commensurate long-range commitment by patients.

Downloaded by [New York University] at 12:14 14 August 2016 Both CBT and pharmacotherapy progress through different phases as patients make therapeutic progress and learn to independently manage their symptoms and take control of their lives. CBT for adult ADHD is designed to start off with regular and relatively frequent meetings in order to target specific functional problems and to understand the interplay of ADHD and comorbid symptoms. As patients grow more confident with the consistent implementation of coping strategies, later sessions are scheduled at longer intervals, such as every second or third week. In fact, the ideal scenario is to have a sufficient number of sessions that represent an adequate “dose” of CBT for adult ADHD with these meeting occurring over enough calendar time to allow for the adequate implementation and integration of coping strategies in one’s daily life. We frame our approach as requiring 16–20 sessions over about Maintenance and Follow-Up 191 6 months in order to achieve sustainable shifts in patterns for coping with ADHD, though they require ongoing efforts to maintain, akin to exercise. The early phase of pharmacotherapy for adult ADHD involves developing a medication regimen that targets problematic symptoms related to executive dysfunction and comorbid conditions. Depending upon patients’ individual responses to medications, subsequent follow-up appointments focus on monitoring the response to medications. Follow-up pharmacotherapy appointments help establish the correct therapeutic dose or address side effects, in some cases necessitating a change in medications. When a stable and effective dose of medication(s) has been achieved, meetings with the prescribing physician are scheduled at longer intervals, allowing for sufficient follow- up monitoring of treatment response. In optimal circumstances, follow-up consultations involve brief assessments to confirm ongoing effectiveness of the medications, to document the absence of side effects, and to renew the prescription. In some cases, the use of particular medications or the presence of medical conditions warrants additional medical examinations or lab tests to monitor the effects of medications on particular body systems and other aspects of general health. Treatment does not always unfold and wrap up in such a smooth progression. Indi- viduals with ADHD may return to CBT in order to address new problems in their lives, which they feel unable to handle, or if they experience “coping drift” away from an effective coping regimen and need more help to reestablish these habits. Similarly, some adults with ADHD stop taking their prescribed medications and cease meeting with their psy- chiatrists, only later to find themselves struggling with recurring symptoms. The purpose of this chapter is to discuss the decision-making process for stopping treatment for adult ADHD and to review how to prepare these patients to maintain treatment gains after the discontinuation of regular clinical appointments. More specifically, we will discuss how these issues are addressed differently in CBT and pharmacotherapy, as the decision to stop each treatment is a distinct one that must be made on its own merits.

Maintenance and Follow-Up: CBT One of the benefits of CBT that consistently emerges from clinical research on CBT for various psychiatric disorders is the maintenance of treatment gains after the completion of active treatment (Butler, Chapman, Forman, & Beck, 2006; Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). That is, CBT involves increasing an awareness of individuals’ cognitive, behavioral, and emotional patterns and developing specific and portable

Downloaded by [New York University] at 12:14 14 August 2016 strategies for handling them (Ludgate, 1995). Thus, someone ideally continues to use these skills after treatment ends, whereas someone who stops taking a medication may be at risk for a relapse of symptoms. This makes intuitive sense because the active ingredient in pharmacotherapy is the pharmacologic agent whereas the active ingredient in CBT is the ability to recognize and modify automatic cognitive, behavioral, and emotional patterns. This remains “in the system” as long as the coping skills are being used. As was mentioned above, there is no definitive time frame establishing when CBT for adult ADHD should end apart from a consensus arrived at by therapist and patient that treatment objectives have been reasonably achieved. In terms of establishing an adequate “dose” of CBT, studies of psychosocial treatments for adult ADHD thus far have varied in the duration of treatments employed, although the average length of treatment programs 192 Maintenance and Follow-Up is around 12–14 sessions of either individual or group treatment. Existing studies of psychosocial treatments range in length from 4 sessions (Wiggins, Singh, Getz, & Hutchins, 1999) to 16 sessions over about 6 months (Rostain & Ramsay, 2006c), although the Wilens et al. (1999) retrospective chart review reported an average of a year of CBT. Recent clinical outcome studies of CBT for adult ADHD have included extended follow-up assessments. That is, participants completing CBT have reported ongoing functional improvements 6 and 12 months after the completion of active treatment that are significantly greater than those reported by participants in active treatment/support control groups (Safren et al., 2010). In the general clinical practice of CBT for adult ADHD, treatment progress is assessed through the collaborative observations of the patient and therapist regarding specific targeted behaviors and outcome measures. Measures of mood, anxiety, and ADHD symptoms are also used to provide additional objective clinical data about treatment response. The implementation of new coping skills, such as the use of a Daily Planner or going through the process of breaking down a large task into its component steps represent concrete examples of change. It is important for the therapist to point out specific behavioral improvements to a patient, as often it requires time between the initial use of coping strategies before desired functional improvements are achieved. Consistent follow-through on tasks recorded in a Daily Planner may be noted before the patient is adept at finishing large projects. There are other markers of positive changes in CBT, such as consistent on-time arrival for sessions, demonstrations of cognitive modification or emotional management skills, as well as establishing good health and sleep habits. Patients may offer examples from their daily lives that resonate for them, such as the experience of submitting a project in advance of a deadline or recognizing that several weeks have passed since car keys have been misplaced. Similar examples of changes related to comorbid problems, such as improved mood or decreased subjective feelings of anxiety are signs of progress. These changes can be further assessed with follow-up ADHD inventories or mood and anxiety rating scales to provide “before-and-after” comparisons with initial scores. As with the initial evaluation, it can be invaluable to gather corroborative observations of patients’ functioning, such as inviting a spouse to attend a session. In some cases, we have found that adults with ADHD underestimate the gains they have made, but they or their significant others point them out when explicitly asked about them. Conversely, however, observers may be susceptible to the “wake effect” seen in assessment of progress in children with ADHD (de Boo & Prins, 2007). That is, it requires about 6 months of

Downloaded by [New York University] at 12:14 14 August 2016 sustained changes before others’ perceptions of the individual with ADHD change. Thus, a person with ADHD makes objective improvements in the number of days during the course of a month he arrives home on time from work but then an incident of lateness is met with the reaction “you’re still always late.” Individuals with ADHD also are at risk for this sort of bias in their self-assessments. Therapists must be mindful of patients professing to be doing well in the face of strong evidence to contrary, which may reflect a “positive bias” and poor self-awareness. Improvements can be discussed and the therapist can then cite the evidence from the patient’s life that indicates “there is more work to be done.” These ongoing areas of difficulty can be framed as opportunities to build on and expand the positive effects of the patient’s coping skills. In some cases, these opportunities reflect newfound coping challenges, such as the person who exhibits improved organization and time management Maintenance and Follow-Up 193 and now must deal with the expectation that these behaviors are the new “norm” and must be maintained to a reasonable degree. In most cases, CBT progresses through a course of sessions that result in a healthy degree of functional improvements that are apparent to both therapist and patient. After a reasonable period of stabilization of functioning, attention turns to preparing to discontinue standing CBT sessions.

Winding Down in CBT There has been a rise in the number of outcome studies of CBT for adult ADHD since the publication of the first edition of this book. With the improved research designs, there has also been improved tracking of the maintenance of clinical improvements after the end of active treatment. Researchers who have performed follow-up assessments of participants who completed psychosocial treatments for adult ADHD have found generally positive results, with many improvements during treatment being maintained at follow-up assessments, up to a year after the end of CBT (e.g., organization skills, ADHD symptoms), while others are not maintained (anger, self-esteem) (Safren et al., 2010; Stevenson, Stevenson, & Whitmont, 2003; Stevenson, Whitmont, Bornholt, Livesey, & Stevenson, 2002). In the course of CBT, individuals are encouraged to progressively assume more control of sessions and take the lead in the problem-management process. Therapists remain as active collaborators but encourage patients to draw on their past experiences and coping strategies to manage situations and determine a course of action. Throughout treatment, but particularly at the outset of treatment and again as sessions decrease in frequency and there is more time between sessions, it is important to remind adults with ADHD that the occurrence of life problems and mistakes is a normal feature of human nature. Thus, the issue is not that these frustrations occur, but rather how they are handled that represents progress. Regarding the long-range management of ADHD, it is important to point out that the relapse rate for ADHD is 100%. It is certain that ADHD adults, even if they are adherent treatment responders to a textbook combination of evidence-based treatments, will encounter problems resulting from executive dysfunction, motivational deficits, or forgetting to use effective coping strategies. Thus, rather than viewing such unavoidable slipups in all-or-nothing terms (e.g., “I guess I’m still at square one.”), CBT encourages the use of a problem-management approach (e.g., “What factors contributed to this situation? What can I do to handle it and to minimize its occurrence?”). This harkens back to

Downloaded by [New York University] at 12:14 14 August 2016 our notion that CBT for adult ADHD provides a framework for understanding how difficulties arise as well as companion coping strategies with which to make changes. There may be factors outside of treatment that necessitate the premature ending of CBT in standard clinical practice. Patients may have a change in insurance coverage or financial circumstances, be assigned a new shift at work that conflicts with the clinician’s office hours, relocate to a new city, or simply drift out of therapy without notice. Ideally, there is an opportunity to wind down sessions and to complete CBT with the final few meetings devoted to generalization of skills and planning for long-range coping. Whether concluding by design or necessity, the major “take away points” from the course of CBT are emphasized during the final meetings. Specific coping strategies that have proven to be useful and effective are highlighted. Examples of problematic situations that arose during treatment and how patients handled them provide a useful blueprint 194 Maintenance and Follow-Up for anticipating future difficulties and for underscoring potentially useful coping strategies to keep in mind. It is useful to recall important “pivot points” at which there seemed to be a positive shift in coping (e.g., “It really seemed that you turned a corner when you devoted time to planning and breaking down you senior thesis during the first week of the semester. You followed through on each of the steps and did not have to rush at the last minute to complete it.”). These instances are highlighted as adaptive reminders for using coping skills to handle future situations, as are other implementation strategies. In addition to reminders that facilitate the use of coping strategies, it is useful to highlight the relevant beliefs and attitudes that are at risk for being reactivated and that could undercut future coping efforts. Adaptive reframes to negative thoughts can be recalled, rehearsed, and recorded for future reference. Various experiences and improvements in the course of CBT can be used to formulate revised beliefs and attitudes, including the management of difficult situations (e.g., “I fell into the old habit of skipping too many classes early in the semester, but I found out that rather than ignoring the problem I could deal with it directly with the professor. I had to drop the class but it would have ended up being a failed course on my transcript had I not reached out to her.”). An important message for ADHD adults to take away from CBT is their documented ability to effectively face problems or tasks head on and to be able to tolerate a degree of emotional discomfort rather than avoiding them—a hallmark of the resilience it is hoped patients will attain. In most research on CBT for adult ADHD, there is a predetermined number of sessions with at least the final meeting devoted to wrapping up, summarizing coping skills, and planning for long-range coping. In standard clinical practice, “ending” CBT is not a unitary concept, with a variety of scenarios for doing so in a therapeutic manner. Some of the more common elements of the termination process are reviewed below.

Wrapping Up and Booster Sessions Whatever the session frequency was throughout CBT for adult ADHD, the ultimate goal is for patients to establish a reasonable degree of proficiency in the implementation of coping skills in daily life, and then to increase the time between sessions. In addition to the implementation of coping skills, the increased time intervals between sessions allows buffer time for adults with ADHD to manage the invariable fluctuations in coping and to practice reimplementing strategies after slipups (e.g., “I was using the planner for several days but set it aside over the weekend, thinking I could keep track of the few things I had to do. By the start of the week, I was feeling disorganized again, so I actually used the idea we dis-

Downloaded by [New York University] at 12:14 14 August 2016 cussed and sat down at lunch on Monday and planned the rest of my day.”). The scheduling of sessions remains flexible and is personalized to each individual, with patients encouraged to contact the therapist if a session is needed sooner than is scheduled, reinforcing the notion that reaching out for help and support is a good problem management skill. On the other hand, as patients move to booster sessions, they may find that as the date of the next session approaches, they are adequately handling their affairs and may call and reschedule the session to a later date, per previous arrangement with the therapist. Once reaching the point of monthly intervals or longer between sessions, the patient is considered to be in “booster session” phase, which could also be considered maintenance phase. Sessions primarily focus on fine tuning the use of coping strategies, drawing on examples of situations and difficulties encountered since the previous session. Maintenance and Follow-Up 195 Time in session sometimes focuses on nuanced coping issues (e.g., “I’m getting a lot better, but I still procrastinate too much on yard work.”), or managing low frequency events (e.g., “I am going to be out of town on business for a week and will have a lot of free time on my own to manage.”), or other opportunities to generalize coping skills. It is useful to reinforce and encourage the preservation of treatment gains and point out examples of improvements in coping compared with at the start of treatment. At some point, the decision will be made to formally end treatment. In many cases, a final session is scheduled, at which time the course of treatment can be reviewed, useful coping strategies identified and reinforced, and potential future issues discussed (e.g., “If you decide to go back to school, how will you handle that process in terms of what we have discussed in sessions?”). There may be a de facto final booster session that ends with the plan of not scheduling a next session, but the patient agrees to call if the need for one should arise. By that point, booster sessions have often already addressed treatment gains and prospective problem management of future issues and long-range coping. However, there may be times when a former patient makes contact well after the end of a course of CBT to seek additional help.

Reengagement in CBT In some cases, patients will return for a single booster session or perhaps a handful of meetings to address a circumscribed issue, such as coping with a new job, adjusting to an academic program, etc. It often seems that describing the issue within the structure of the session helps the patient break it down and identify how to manage it within a therapeutic context that has been helpful before. However, emergent life issues may be more complex than can be addressed in a brief consultation, and a reengagement in CBT may be indicated. Patients sometimes decide to resume CBT for adult ADHD to manage their adjustment to major life changes, such as coping with divorce, organizing a job search after being graduated from college or losing a job, dealing with the newfound demands of being a parent, etc. Although the aforementioned life stressors are not limited to adults with ADHD and are pressures faced by most people, the features of ADHD complicate efforts to cope with them. It is easy to have the sense that “we can pick up where we left off” in terms of the familiarity and positive alliance between patient and therapist. Based on this optimistic view of CBT regarding past benefits, there is an inclination on the part of both clinician and patient to “jump back into” CBT as though it is merely the “next session.” Instead,

Downloaded by [New York University] at 12:14 14 August 2016 the resumption of CBT should be viewed as a new course of treatment that requires new targets. Hence, it is useful to stay true to the protocol of defining treatment goals in specific terms and setting out realistic expectations for outcomes (e.g., “organize and implement the specific steps involved in a job search” vs. “get a job”). Similar to the initial course of CBT, there will be a learning curve, and it will be important to normalize that it may take time and persistence to manage the new life situation. One of the challenges in treating adult ADHD, as compared with children or adolescents, is that adult life often involves an accumulation of demands and obligations that becomes ever more complicated. Hence, when adult ADHD patients reengage in CBT, even though there may have been a very positive and adaptive initial course of treatments, the second round of treatment often is more complex than the first round as 196 Maintenance and Follow-Up there may be new and different clinically relevant variables from those that were present during the initial round of CBT. For example, a college student with ADHD initially sought CBT during the first semester back after taking an academic leave of absence. She discontinued treatment after successfully completing two consecutive semesters. However, she asked to resume CBT a few years after graduation, now living as a solo parent of a 1-year-old child and working full-time. She still sought help with time management and organizational skills, but they now applied to a broader range of roles and duties, which required an adjustment of the therapeutic approach. For example, if she missed a class in college, she did not have to reschedule it; but if she missed a pediatrician appointment for her son, she had to reschedule it and request time off from work for it. Although perhaps having a different feel than the first course of CBT, there is still the potential for a patient to build on and generalize coping skills and tactics to manage new and more complex life demands. The next section will review some of the important coping strategies for adults with ADHD to use after the end of formal CBT sessions.

Important Coping Strategies and Resources to Use After the End of CBT Of course, it is important for adults with ADHD to use the full assortment of coping strategies that have been introduced during CBT in order to manage their lives. However, there are a few special strategies and resources that many adults with ADHD find helpful to consider as part of their ongoing coping efforts in order to maintain well-being.

Self-Advocacy, Assertiveness, and Asking for Help A common adage regarding the management of ADHD is that “ADHD is not your fault, but it is your responsibility.” The aforementioned saying makes two points about ADHD. The first point relates to the etiology of ADHD. That is, ADHD in and of itself does not reflect poor character but rather stems from genetic predispositions for a particular neurobiological profile that result in the downstream observable symptoms and dysfunctions. The second point made about ADHD relates to the management of the effects of ADHD, particularly for adults. That is, with the diagnosis comes the personal responsibility to take steps to make changes in one’s life and to manage one’s behaviors. This outlook does not mean that adults with ADHD must be perfect and cope in isolation;

Downloaded by [New York University] at 12:14 14 August 2016 rather, being conscientious about one’s welfare includes developing the ability to identify and to pursue necessary services, supportive technology, and assistance from others. We view the ability to ask for help, what is often referred to as “self-advocacy,” as reflecting assertiveness, effective problem management, and overall good coping. Self-advocacy is particularly relevant for adults with ADHD in academic or work settings. Being a college student with ADHD often requires seeking additional support from a professor or academic counselor, or petitioning the college Office of Student Disabilities for reasonable academic accommodations. Students may be reticent to initiate these steps because they have not had to do so in the past, due to thoughts along the lines of, “I should be able to do this myself if I just work a little harder,” or simply due to uncertainty or lack of information (e.g., “What documentation do I need?” or “What am I going to say Maintenance and Follow-Up 197 to or ask my professor if I go to her office hours?”). Another useful self-advocacy skill is making use of instructor office hours for extra help or communicating with the instructor when having difficulties in class or regarding attendance matters. These sorts of behaviors are good therapeutic homework tasks for college students with ADHD in order to tap into available resources. The task can be framed as a “do-it-at-least-once” experiment to provide the patient with an opportunity for a useful experience. ADHD adults in the workplace face a thornier situation. These individuals may be understandably reticent to share personal information about ADHD with an employer, being unsure how it may be used. What is more, employers vary in their flexibility and willingness to be accommodating to different working styles. We hope that ongoing public education about adult ADHD increases employers’ awareness of its negative impact on work productivity in traditional work settings and stimulates diverse ways that workers can demonstrate their talents. At the same time, we also appreciate that revealing a diagnosis of ADHD is a risky proposition for some workers. Even so, seeking assistance from an ADHD Coach or engaging in problem management with a supervisor about a specific workplace situation (without mentioning ADHD) are alternative ways to handle commonly encountered problems. For workers or students with ADHD, the pertinent coping skill is the ability to identify the problem at hand and to be able to speak up and ask for help, when needed. We have observed that assertiveness is an underrated coping skill within CBT for adult ADHD. Individuals with ADHD often describe operating from a “deficit” when it comes to asking for help. A common theme is, “It always seems that other people are accommodating me or I am late showing up or I forget to do things—how can I ask for more help?” We often observe that this attitude is overgeneralized from past experiences or other relationships in the person’s life. Thus, we work with patients to make distinctions among different settings, people and their roles, and the specific requests to be made. So, for example, an employee whose boss is forgiving of his lateness is now reticent to ask for weekly check-in meetings on a large project, thinking he had already used up his allotment of “favors” he could expect. We differentiated the issues of timely arrival to work and completion of the project as reflecting different “roles” he had with his boss. Thus, the fact he was forgiven for his lateness did not negate the option of asking for help on the project. In terms of implementing self-advocacy behaviors, we developed a specific behavioral plan or “making a request” script, the reminder being that “once you have made the request, you have completed your ‘job.’” The other person’s “job” is now to consider the request and provide his or her answer, which is out of the patient’s control. Downloaded by [New York University] at 12:14 14 August 2016 Community Support/Psycho-education Studies of group CBT treatments for adult ADHD have reported that participants find the interaction with other group members as a useful and important component of their positive outcomes (Hesslinger et al., 2002; Solanto, 2011). Drawing on these findings as well as the anecdotal reports of many patients in individual treatment, seeking out ongoing psycho-education about ADHD and having connection to a supportive network or community can be helpful in the long-term management of ADHD. Personal education may take the form of reading popular books about coping with ADHD or about specific topics, such as the effect of ADHD on marriage or helping 198 Maintenance and Follow-Up teens with ADHD get ready for college. Psycho-education is particularly relevant for an adult with ADHD because there are so many different life roles that are affected by ADHD, such as parenting, committed relationships, work, etc. Reputable websites, social networking sites, etc. provide a repository of information as well as contact with other adults with ADHD (see Appendix A). As mentioned above, social networking provides a convenient way to establish and maintain contact with a community of individuals affected by and/or interested in ADHD. It also is a source of expert information in many cases. There are many venues for regular support group meetings that may offer guest speakers as well as an opportunity to socialize with other adults with ADHD. There are several reputable national and regional ADHD organizations that host national and regional conferences as well as online webinars that provide an opportunity for concurrent exposure to cutting edge information and connection with the ADHD community.

Commitment to the Long-Term Management of ADHD Coping with ADHD does not end after the final session of CBT or after ingesting a prescribed pill. Living with adult ADHD requires a long-term commitment to managing its effects. The goal of CBT for adult ADHD is to promote the consistent and persistent implementation of coping strategies in daily life in order to improve functioning and well-being. There is strong empirical evidence from a number of studies as well as common sense that these coping skills work, but they must be used to reap the benefits. Coping with ADHD is akin to developing a health and exercise routine. There will be some behaviors that become habitual and require less concerted effort to maintain, such as the use of a Daily Planner or keeping important items in a consistent place to avoid misplacing them. These coping habits are akin to the shift in health habits, such as drinking water rather than a high-caloric drink or taking the stairs rather than riding in an elevator. There will be other tasks that require more concerted efforts to manage, such as breaking down a large project into its component parts, or identifying and reducing procrastination on tasks, which are akin to a discrete physical workout on an elliptical machine or having a strategy for handling unexpected disruptions to one’s plans. As with a health/exercise routine, slipups are the rule rather than the exception. It is not whether there will be a disruption (e.g., skip a workout) but rather how it is handled (e.g., resume the next scheduled workout). The commitment to the long-term management of ADHD involves making informed decisions about various external aspects of

Downloaded by [New York University] at 12:14 14 August 2016 life with regard to the influence of ADHD. Hence, there are steps such as setting up automatic payments of bills or having a visible household calendar on which important appointments and obligations are recorded. Long-term coping also requires an investment of time and effort to “undo” the backlog of effects of ADHD that have built up in one’s life. Assessment and treatment will likely force many people to face and come to terms with the impact of ADHD on different aspects of their lives. Hence, many adults with ADHD will have to confront their financial debt, incomplete education, health issues, or other effects of longstanding executive dysfunction and motivation deficits. In addition to “starting small” and having specific targets for change within these domains (e.g., “I will automate my payments to avoid late fees.”), there is the need to commit to these changes over the long term in order to achieve an enduring sense of stability. Maintenance and Follow-Up 199 The CBT skills mentioned throughout this volume provide clinicians treating adults with ADHD with anchor points to which they can return when facing challenges during the course of psychosocial treatment. That is, the CBT model provides clinicians with a frame to help their patients with ADHD understand “how they do not do things.” From that recognition, there is the opportunity to develop adaptive action plans that represent ways to deal with ADHD in their daily lives to improve functioning and well-being. Phar- macotherapy is usually delivered in combination with CBT for adult ADHD. Likewise, it is important to consider maintenance and follow-up issues involved in medication management for adult ADHD, which is the focus of the next section of this chapter.

Maintenance and Follow-Up: Pharmacotherapy Just as individuals have beliefs about medications that affect their willingness to start a course of pharmacotherapy, it is important to assess beliefs about ongoing medication management, particularly after an extended period of stable, improved functioning. At the start of patients’ pharmacotherapy, we frequently encounter the question, “How long will I need to take these medications?” When considering ongoing medication management the question becomes, “How much longer will I need to take these medications?” This may also be coupled with a concern about the long-term health effects of continuing pharmacotherapy. The answer to this question is variable, and it depends on the goals and beliefs that patients have about medication treatment. If patients are unrealistically hoping for a medication to repair their “faulty” neurobiology, it is important to reinforce the notion that ADHD is “hard-wired,” and that medications only meliorate the neural mechanisms that underlie the disorder. While implementation-focused CBT, environmental reengi- neering, new strategies for problem solving, and improved social support can all contribute to an improved quality of life for patients, the ADHD brain generally remains disordered to greater or lesser degrees. While this is very difficult for patients to accept on an emotional level, it is a basic truth about all neurodevelopmental disorders, and it needs to be acknowledged by patients in order for them to make appropriate decisions about taking medications on a long-term basis. Like other chronic disorders, this decision needs to be made on the basis of cost-benefit analysis. That is, what are the risks, hazards, and costs (financial, medical, and psychological) as well as the benefits of continuing versus discontinuing medication treatment? This is the basic set of questions that patients and clinicians must face over the long term. To help patients answer this, we find it is useful to draw an analogy between ADHD

Downloaded by [New York University] at 12:14 14 August 2016 and a medical disorder like hypertension. Even after following a healthy diet, losing weight, exercising regularly, and maintaining a positive mental attitude, many patients are still plagued by high blood pressure as a result of abnormal cardiovascular physiol- ogy. What are the hazards, risks, and costs versus the benefits of taking blood pressure medication versus not taking medication? This decision faces millions of Americans on a daily basis. It is well established that lowering blood pressure reduces the incidence of stroke, heart attacks, and premature deaths from the complications of hypertension, but it is also well recognized that most patients do not comply with their prescribed medical treatments. While it is clear that hypertension is different from ADHD, we find the analogy compelling because it emphasizes to patients that there are no clear-cut “right or wrong” answers. Fortunately, there is now a growing body of evidence to suggest that ADHD medications are not associated with any long-term health risks (see Fredriksen, 200 Maintenance and Follow-Up Halmoy, Faraone, & Haavik, 2013; Habel et al., 2011; Santosh, Sattar, & Canagaratnam, 2011), especially with respect to life-threatening cardiovascular events or to chronic conditions like high blood pressure or diabetes. Many individuals adopt an “If it’s not broke, don’t fix it” attitude and are satisfied with maintaining a stabilized and effective medication regimen. In other cases, we hear individuals who say “I’m ready to try things on my own” as they plan to discontinue their medications. While it is often preferable for patients to continue pharmacotherapy, there is nothing wrong with deciding to discontinue medications periodically to observe what happens. This approach serves to reinforce for the patient that he or she is the ultimate decision maker. It also enables the patient to conduct an empirical trial to determine if indeed the medication is contributing to his or her daily functioning. Whenever the decision is made to discontinue pharmacotherapy, it is best if the patient does so in a careful and well thought-out way, always in collaboration with the prescribing clinician. The medication(s) should be tapered or discontinued in a manner that minimizes potential side effects from discontinuation. The patient should observe his or her concentration, mood, and behavior prior to and immediately after stopping the medication, preferably by utilizing the medication log or some other standardized record of target symptoms. Finally, it is best to schedule a follow-up appointment in 1 month to reassess how the patient is doing and to gauge how the cessation of medication has impacted on ADHD and comorbid symptoms. If there are no adverse effects seen from the discontinuation, or if the patient finds that a return of ADHD symptoms is not causing serious impairment, it is important to emphasize that if things change for the worse and if the patient reexperiences impairing symptoms, it would be worthwhile to return for a medication reevaluation. College students in particular seem to struggle with issues related to ongoing use of prescribed medications, even when they acknowledge their benefits. In our experience, it is best to adopt a flexible clinical stance with respect to the ambivalence expressed by patients at this developmental stage. Young adults are particularly worried about how they can com- bine medications with alcohol, marijuana, and other recreational drug use. We point out that it is up to them to learn how to regulate the medication regimen to best suit their treatment goals, and we emphasize the value of moderation in all aspects of daily living. At times, there are concerns about long-term dependence on medication. The best response to these issues is to reinforce the notion that this is up to the patient to decide and that the choices will become clearer for him or her as they enter the next phase of their lives after college.

Chapter Summary Downloaded by [New York University] at 12:14 14 August 2016 Managing the effects of ADHD is an ongoing proposition. It is a chronic, neurodevelopmental syndrome that affects functioning every day and, therefore, requires coping every day. We frequently refer to the need for resilience throughout our combined treatment approach. That is, it is normal for individuals to experience difficulties and setbacks, both during treatment and after it ends. Effective coping for adult ADHD is not defined by the absence of problems but rather by having ways to understand them and to manage them. Our notion of an attitude of resilience that we wish for all our patients remains best captured by a quote attributed to an anonymous college student-athlete that we used to close out the first edition of this book but that remains apropos: “I’m going to graduate on time, no matter how long it takes me.”

Appendix A Informational Resources About Adult ADHD

Online Resources and Organizations Regarding Adult ADHD • Attention Deficit Disorder Association (ADDA)—www.add.org (Largest organization solely dedicated to ADHD issues faced by adults) • Children and Adults with Attention Deficit Disorder (CHADD)—www.chadd.org • National Resource Center for ADHD—www.help4add.org (CHADD-sponsored website providing information about ADHD across the lifespan) • Canadian ADHD Resource Alliance (CADDRA)—www.caddra.ca (Provides Canadian guidelines for the treatment of ADHD and many other resources) • ADDISS—www.addiss.co.uk (British organization providing information about ADHD across the lifespan) • Totally ADD—www.totallyadd.com • Association on Higher Education and Disability (AHEAD)—www.ahead.org • Learning Disabilities Association of America (LDA)—www.ldanatl.org • ADD Resources—www.addresources.org

Recommended Readings About Adult ADHD: For Consumers (We’ve limited this list to books published since the first edition of our book.) • Barkley, R. A. (2010). Taking charge of adult ADHD. New York: Guilford. • Brown, T. E. (2014). Smart but stuck: Emotions in teens and adults with ADHD. New York: Jossey-Bass. • Levrini, A., & Prevatt, F. (2012). Succeeding with adult ADHD: Daily strategies to help you achieve your goals and manage your life. Washington, DC: American Psychologi- Downloaded by [New York University] at 12:14 14 August 2016 cal Association. • Orlov, M. (2010). The ADHD effect on marriage. Plantation, FL: Specialty Press. • Pera, G. (2008). Is it you, me, or adult A.D.D.? San Francisco: 1201 Alarm Press. • Ramsay, J. R., & Rostain, A. L. (2015). The adult ADHD tool kit: Using CBT to facilitate coping inside and out. New York: Routledge. • Ratey, N. (2008). The disorganized mind: Coaching your ADHD brain to take control of your time, tasks, and talents. New York: St. Martin’s Press. • Safren, S. A., Sprich, S., Perlman, C. A., & Otto, M. W. (2005). Mastering your adult ADHD: A cognitive-behavioral treatment program—Client workbook. Oxford: Oxford University Press. 202 Appendix A • Surman, C., & Bilkey, T. (2013). Fast minds: How to thrive if you have adult ADHD (or think you might). New York: Penguin. • Tuckman, A. (2009). More attention, less deficit: Success strategies for adults with ADHD. Plantation, FL: Specialty Press. • Tuckman, A. (2012). Understand your brain, get more done: The ADHD executive functions workbook. Plantation, FL: Specialty Press. • Zylowska, L. (2012). The mindfulness prescription for adult ADHD. Boston: Trumpeter.

Recommended Readings About Adult ADHD: For Clinicians • Barkley, R. A. (2012). Executive functions: What they are, how they work, and why they evolved. New York: Guilford. • Barkley, R. A. (2014). (Ed.). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford. • Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. New York: Guilford. • Brown, T. E. (2013). A new understanding of ADHD in children and adults: Executive function impairments. New York: Routledge. • Gregg, N. (2009). Adolescents and adults with learning disabilities and ADHD: Assess- ment and accommodation. New York: Guilford. • Hinshaw, S. P., & Scheffler, R. M. (2014). The ADHD explosion: Myths, medication, money, and today’s push for performance. New York: Oxford University Press. • Kooij, J. J. S. (2013). Adult ADHD: Diagnostic assessment and treatment. London: Springer-Verlag. • Mapou, R. L. (2009). Adult learning disabilities and ADHD: Research informed assessment. New York: Oxford University Press. • Monastra, V. J. (2008). Unlocking the potential of patients with ADHD: A model for clinical practice. Washington, DC: American Psychological Association. • Nigg, J. T. (2006). What causes ADHD?: Understanding what goes wrong and why. New York: Guilford. • Ramsay, J. R. (2010). Nonmedication treatments for adult ADHD: Evaluating impact on daily functioning and well-being. Washington, DC: American Psychological Association. • Tuckman, A. (2007). Integrative treatment for adult ADHD: A practical, easy-to-use guide for clinicians. Oakland, CA: New Harbinger.

Downloaded by [New York University] at 12:14 14 August 2016 CBT for Adult ADHD: Treatment Manuals • Hesslinger, B., Philipsen, A., & Ricther, H. (2004). Psychotherapie der ADHS im erwachsenenalter: Ein arbeitsbuch. Göttingen: Hogrefe-Verlag. • Ramsay, J. R., & Rostain, A. L. (2015). Cognitive behavioral therapy for adult ADHD: An integrative psychosocial and medical approach (2nd ed.). New York: Routledge. • Safren, S. A., Perlman, C. A., Sprich, S., & Otto, M. W. (2005). Mastering your adult ADHD: A cognitive-behavioral treatment program—Therapist guide. Oxford: Oxford University Press. Appendix A 203 • Solanto, M. V. (2011). Cognitive behavioral therapy for adult ADHD: Targeting executive dysfunction. New York: Guilford. • Weiss, M. D. (2008). A manual for problem focused therapy of attention-deficit hyperactivity disorder in adults. Unpublished manuscript. • Young, S., & Bramham, J. (2012). Cognitive-behavioural therapy for ADHD in adolescents and adults: A psychological guide to practice (2nd ed.). West Sussex, England: Wiley.

Downloaded by [New York University] at 12:14 14 August 2016 Appendix B Outline of a Typical CBT Session for Adult ADHD

• Check-in: Symptom check (e.g., recent life events, ADHD, mood, medication issues) • Agenda setting: Includes review of homework and other priority issues for the session • Review homework task: Review coping skill progress and address any difficulties, including difficulties remembering and implementing the tasks • Agenda items: Specific issues to be addressed in session, primarily the implementation of coping skills for managing ADHD (though it is important to invite patients to feel free to bring up other issues that affect their well-being, which will likely be affected by ADHD, too) • Summary and homework/“ take away” task: Wrap up and develop homework/take away task, such as the use of a coping skill, implementation strategies, to deal with difficulties using a coping skill, or other examples of monitoring and changing patterns in order to improve coping and functioning.

Downloaded by [New York University] at 12:14 14 August 2016 Appendix C Outline of a 20-Session/6-Month Course of CBT for Adult ADHD

• Session 1 (Getting Started) Develop and defi ne treatment objectives (“start small”) Elicit highly specifi c examples of problem areas (e.g., thoughts, feelings, behaviors) (The question “How do you decide what is important to do and how do you go about doing it?” often yields helpful initial targets for treatment.) Address “readiness for change” and motivational issues Develop initial homework task (anticipate potential problems) • Session 2 (Getting Started, continued) Review initial homework task and assess outcome—handle initial diffi culties (Even if the homework task is not completed or only partially attempted, it provides examples of the diffi culties commonly encountered in daily life.) Prioritize other agenda items and treatment goals (including motivational issues) Summary and homework • Sessions 3–6 (Early Phase) Continue to develop initial case conceptualization from information gathered in sessions and from initial evaluation (The conceptualization may be relatively uncomplicated and focused on circumscribed coping skills and reactions or may be involve more complex emotional reactions, behaviors, and thoughts/beliefs.) Focus on relevant skill-based interventions for ADHD-related diffi culties Address relevant interaction of comorbid problems and ADHD Downloaded by [New York University] at 12:14 14 August 2016 • Sessions 7–15 (Middle Phase) Ongoing focus on coping skills and handling initial setbacks Address comorbidities Use of case conceptualization to target relevant beliefs and compensatory strategies that are relevant to functioning Start to increase interval between sessions (often using natural breaks in scheduling, i.e., holidays or vacations, as a way to experiment with new intervals) • Sessions 16–20 (Final Phase) Support trust in patient’s new abilities Normalize setbacks and adopt problem-solving attitude (e.g., relapse prevention) 206 Appendix C Generalize treatment gains Review revised beliefs Assess overall functioning Develop long-term coping plan • Booster sessions (as needed) Booster (or regular) sessions to continue to address ongoing coping diffi culties Address coping skill “drift” Deal with emergent life issues affected by ADHD (e.g., new job, parenting, etc.) Focus on lingering compensatory strategies or coping skill diffi culties Schema revision Continued focus on “doing what works” Downloaded by [New York University] at 12:14 14 August 2016 Appendix D Typical Medications Prescribed to Treat Adult ADHD

Generic class Form Strength Max Dose Administration (Brand Name) for Adults

Atomoxetine HCl* (Strattera®) caps 10mg, 18mg, 1.4mg/kg or • Swallow whole 25mg, 40mg, 100mg/day • Give once daily in 60mg, 80mg, (whichever the morning or in 100mg is less) 2 divided doses • May discontinue without tapering dose Clonidine HCl (Kapvay®) Ext-rel tabs 0.1mg, 0.2mg 0.2mg twice • Swallow whole daily • Titrate by response • Withdraw gradually by 0.1mg/day at 3- to 7-day intervals Dextroamphetamine sulfate (Dexedrine®) Scored tabs 5mg, 10mg Usually • Give in AM and then 40mg/day in 1–2 more doses 4–6hrs 2–3 divided apart doses (Dexedrine Sust-rel caps 5mg, 10mg, Usually • Avoid late evening spansules®) 15mg 40mg/day doses Dextromethylpheniate HCl (Focalin®) Tabs 2.5mg, 5mg, 20mg/day • Give twice daily at least 10mg 4hrs apart • Single isomer Downloaded by [New York University] at 12:14 14 August 2016 methylphenidate product (use ½ of racemic methylphenidate dose initially) (Focalin Ext-rel caps 5mg, 10mg, 40mg/day • Give once daily in the XR®)* 15mg, 20mg, morning 25mg, 30mg, • May sprinkle contents 35mg, 40mg on applesauce and swallow without chewing beads

(Continued) 208 Appendix D (Continued)

Generic class Form Strength Max Dose Administration (Brand Name) for Adults

Guanfacine (Intuniv®) Ext-rel tabs 1mg, 2mg, 3mg, 4mg/day • Swallow whole with 4mg water, milk, or other liquid • Do not give with high- fat meals • Withdraw gradually by 1mg every 3–7 days Lisdexamfetamine dimesylate* (Vyvanse®) Caps 20mg, 30mg, 70mg/day • Give once daily in the 40mg, 50mg, morning 60mg, 70mg • May sprinkle contents in a glass of water and consume immediately Methamphetamine HCl (Desoxyn®) Tabs 5mg Usually • Give once or twice 20–25mg daily 30min before daily in two meals divided • May increase at weekly doses intervals Methylphenidate (Daytrana®) Transdermal 10mg, 15mg, — • Apply patch to hip patches 20mg, 30mg 2hrs before desired effect, remove 9hrs after application; may remove earlier if shorter duration of effect or late day side effect appears • May titrate dose at 1-wk intervals Methylphenidate HCl (Concerta®)* Ext-rel tabs 18mg, 27mg, 72mg/day • Give once daily in the (with immed 36mg, 54mg morning rel outer coating) Downloaded by [New York University] at 12:14 14 August 2016 (Metadate Ext-rel tabs 10mg, 20mg, 60mg/day • Give once daily in CD®) (with immed 30mg, 40mg, the morning before and ext-rel 50mg, 60mg breakfast beads) • May sprinkle contents on applesauce and swallow without chewing beads (Metadate Ext-rel tabs 20mg 60mg/day • May use Metadate ER® ER®) in divided when its 8-hr dose doses corresponds to the 8-hr immed-rel dose Appendix D 209

Generic class Form Strength Max Dose Administration (Brand Name) for Adults

(Methylin®) Tabs 5mg 60mg/day • Give before breakfast Scored tabs 10mg, 20mg in divided and lunch doses (Methylin Chew tabs 2.5mg, 5mg, 60mg/day • Give before breakfast chewable®) 10mg in divided and lunch doses (Methylin Ext-rel tabs 10mg, 20mg 60mg/day • May use Methylin ER® ER®) in divided when its 8-hr dose doses corresponds to the 8-hr immed-rel dose (Methylin oral Oral soln 5mg/5mL 60mg/day • Give before breakfast solution®) 10mg/10mL in divided and lunch doses (Quillivant Ext-rel oral 25mg/5mL 60mg/daily • Give once daily in the XR®) susp morning • Shake bottle vigorously for > 10 sec before use (Ritalin®) Tabs 5mg 60mg/day • Give before breakfast Scored tabs 10mg, 20mg in divided and lunch doses (Ritalin LA®) Ext-rel tabs 10mg, 20mg, 60mg/once • Give once daily in the (half as 30mg, 40mg daily morning immed-rel, • May sprinkle contents half as e-c on applesauce and delayed-rel swallow without beads) chewing beads (Ritalin SR®) Sust-rel tabs 20mg 60mg/day • May use Ritalin SR® in divided when its 8-hr dose doses corresponds to the 8-hr immed-rel dose Mixed dextroamphetamine/ amphetamine salts (Adderall Double scored 5mg, 7.5mg, Usually • Give in AM and 4–6hrs IR®) tabs 10mg, 12.5mg, 40mg/day in apart 15mg, 20mg, 2–3 divided 30mg doses (Adderall Ext-rel caps 5mg, 10mg, 30mg once/ • Give once daily in the XR®)* 15mg, 20mg, daily morning 25mg, 30mg • May sprinkle contents Downloaded by [New York University] at 12:14 14 August 2016 on applesauce and swallow without chewing beads

*FDA approval for adult ADHD. References

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Downloaded by [New York University] at 12:14 14 August 2016 Index

Note: Page numbers followed by f indicate a figure, and page numbers followed by t indicate a table on the corresponding page.

Acceptance and Commitment Therapy (ACT) anterior cingulate cortex (ACC) 24–5 84, 94 anticipation of future 38, 40, 70, 72, 74 t, 141 acceptance-mindfulness intervention 84–6 anticontemplation stage of change 170 accountability concerns 98, 103, 167 antisocial personality disorder 16, 42 adaptive anxiety 40 Anxiety Disorder, Not Otherwise Specified 145 adaptive coping skills: alternate approaches to anxiety disorders: cognitive behavioral therapy 142; cues for 83; development of 42, 54, 68, for 47; Generalized Anxiety Disorder 145, 166; identifying targets 64; maintenance of 153; introduction 15, 16; mood/anxiety 102, 107, 170 ratings 36; overview 39–40; adaptive thinking 58, 71 pharmacotherapy 114 Adderall XR 116, 132, 147, 163 Asperger’s Disorder 43 ADHD, Not Otherwise Specified (NOS) 11 assertiveness 142, 158, 196–7 Adult ADHD Investigator Symptom Rating asthma 16 Scale (AISRS) 127 Atomoxetine (ATX) 12, 113, 115, 132–4, 189 Adult ADHD Self Report Scale 26, 111 auditory working memory 35, 37, 138, 146, Adult ADHD Symptom Rating Scale-Screener 26 154, 161 Adult ADHD Treatment and Research autistic spectrum disorders 43 Program xii–xiii automatic reminders 103 Adult Attention Deficit/Hyperactivity automatic thoughts: changes to 70–5, 74 t, 76, Disorder (ADHD): defined 4–5, xi–xii; 83; cognitive behavioral therapy and 48, evaluation for 1; neuropsychologic studies 57–9; executive dysfunction management of 24; persistence and prevalence of 12–15; 99; identification of 77; monitoring of 86 pharmacotherapy for 111–15; reactions to awfulizing 74t, 94 182–5; reaction to diagnosis 60–2; see also diagnosis, symptoms, etiology, and Barkley, R.A. 13, 19, 35

Downloaded by [New York University] at 12:14 14 August 2016 assessment; diagnostic criteria and Barkley Adult ADHD Rating Scales-IV symptoms across lifespan; Specific (BAARS-IV) 32–3 interventions Barkley Deficits in Executive Functioning adult oppositional behavior 175–7 Scale (BDEFS) 35, 138 affect regulation 20, 125 Barkley Functional Impairment Scale all-or-nothing thinking 74t, 85, 102, 157, 166, (BFIS) 35 176, 193 Beck Anxiety Inventory (BAI) 36 alpha adrenergic agonists 113, 133 Bedway, M. 43 American Academy of Child and Adolescent behavioral inhibition 19–20, 68, 70–1, 156 Psychiatry (AACAP) 131 behavioral interventions 69, 78–81, 84, 125 Amphetamine (AMP) 114, 116, 131–2, 163 behavioral scripts: case examples of 141, 143, Anastopoulos, A.D. 130 157, 166–7; complicating factors and 180, 230 Index 182; coping and 171; development of and 70–1; clinical case examples 143, 151, 79–80, 82, 184, 189; follow-through 95 157–8; complicating factors 176–7, 180; Behavior Rating Inventory of Executive control studies on 121; impact of 99–101; Function (BRIEF) 3–4, 35 maintenance and follow-up 192; overview 78, bipolar disorder 16, 40–1, 47, 115, 153 85, 101, xii; task-interfering thoughts 82, 86 blame, externalizing 43, 74 t, 175–7, 182 cognitive remediation programme (CRP) 119, booster sessions 123, 194–5, xiv 126–7 Bornholt, L. 126 community support 197–8 Bramham, J. 126 comorbidity and Adult ADHD 13, 38–44, xvi brinksmanship 9, 40, 55 t comparative thinking 74t, 100–1 British Association for Psychopharmacology 131 compensatory strategies: case Brown Attention Deficit Disorder Scale for conceptualization 50, 51 f, 64; clinical case Adults (BADDS) 11, 33, 35, 120–1, 129 examples 149, 158, 167; complicating buffer time in scheduling 91, 194 factors 172; core beliefs and 53; influences bupropion (antidepressant) 113–15, 117, 133–4, on 59; overview 54–7, 55 t 147, 189 complicating factors: medication-related 187–9; Burke, Edmund 3–4 motivation and commitment 169–71; overview 169; physical/medical well-being Canadian ADHD Resource Alliance 177–80; reactions to ADHD patients 182–5; (CADDRA) 131 significant impairment 185–7; technology check-in meetings 71, 98–9, 103, 145, 184, 197 31–2, 180–2; treatment complicating chronic fatigue syndrome 29 behaviors 171–7 clonidine 111, 113, 115, 117, 131, 133 Comprehensive To-Do List 86–7 cognitive behavioral therapy (CBT): Concentration Deficit Disorder (CDD) 6, accountability and 98; adaptive coping skills 11–12 42; agenda items 68–70; behavioral Concerta 116, 132, 143, 156 principles in 78; case conceptualization Conduct Disorder 7, 42 48–59; case studies on 156–9, 164–8; Conners’ Adult ADHD Rating Scales (CAARS) categories of interventions 70–86; in clinical 11, 33–4, 125, 127–8 practice 59–70; coping strategies and contemplation stage of change 170 resources after 196–9; diagnosis reactions coping skills/strategies: behavioral scripts 171; 60–2; effectiveness of 2, 38, 120–1; Daily Planner and 89; development of 75, individual approaches 119; introduction 79; environmental engineering 106–7; 116, xii–xiii; lying behavior and 173; follow-through as 47, 83–4; if-then coping maintenance and follow-up 191–2; plans 53, 82; maintenance and follow-up modularized treatment 59–60; motivation 196–9; in materials management 105–6; to change 62–3, 169–71; overview 46–8; outsourcing coping skills 102–3; problem psycho-education 63; reengagement in management/decision making 107–10; 195–6; rubric for prioritization 88; sessions scaffolding for 68, 142; specific structure 67–8; studies on 119–21; interventions 86–110; see also adaptive summary of 110–11; therapeutic alliance coping skills 65–7; treatment goals 63–5; winding down core beliefs 53–4, 54t, 75–8 in 193–4; see also Group Cognitive cortical thinning 23 Downloaded by [New York University] at 12:14 14 August 2016 Behavioral Therapy cognitive behavioral therapy (CBT), case Daily Planner: clinical case examples 139, 141–2, conceptualization: automatic thoughts, 148, 156, 164–5; complicating factors 178, emotions, and behaviors 57–9; 181, 183; in maintenance and follow-up compensatory strategies 54–7, 55 t ; 192, 198; motivation and 98; overview developmental experiences 52–3; impact of 86–93; use of 64, 103–4, 106, 108 169; neurobiology and environment Daily To-Do List 86–9, 91, 98, 139, 142, 147–8 interaction 50–2, 51 t ; overview 48–50; real- data management 103–5 life examples and 67; schema and core decision making 24, 99, 107–10, 191 beliefs 53–4, 54 t default mode network 24–5 cognitive modification interventions: asking Defense Attorney metaphor 71, 72, 100, 102, questions as 73, 94–5; automatic thoughts 158, 171 Index 231 deficient emotional self-regulation (DESR) 38, for 125; negative impact of 177; overview 42, 50, 175 17, 19–21; reverse engineering impairments depression: in clinical case examples 145, 152, 49; specific interventions for 86; standardized 153, 155, 160–1; cognitive behavioral ratings of 34–5; Total EF score 35 therapy for 47; introduction 11, 15, 16; exercise habits: benefits from 60, 87, 92, 178–9; overview 36, 38–9; pharmacotherapy 114, follow-through 157, 198; medication and 117, 120–1 156; prioritization of 88–9, 177 desipramine 113, 131, 134 developmental experiences 48, 52–3, 65, 76 fallacy of fairness 74 t developmental history 27–30, 44, 48, 59, 154 family history 27–8 developmental-social learning disorders 43–4 F-A-S Task test (FAS) 37 “Devil’s Advocate” position 94 follow-through: as coping strategy 47, 83–4; diagnosis, symptoms, etiology, and assessment: exercise habits 157, 198; promotion of 95, 97 comorbidity and 38–44; components of four quadrant approach to tasks 88 26–30; diagnostic criteria and symptoms fraternal/dizygotic (DZ) twins studies 21 across lifespan 5–12; etiologic models Freud, Sigmund 53, 57, 76, 99 18–26; introduction 2–5; life outcomes functional impairments: causes 27; clinical 16–18; neuropsychological screening 36–8; case examples 167–8; complicating factors overview 1–2; persistence and prevalence of 185; maintenance and follow-up 192–3; ADHD 12–15; psychiatric comorbidity medication and 116–17, 119, 122–3, 129; 15–16; structured diagnostic interview 30–6 ratings of 35; symptoms 6, 14, 32; treatment Diagnostic and Statistical Manual of Mental 46–8 Disorders (5th ed.) 4, 5, 13 Functional Magnetic Resonance Imaging diagnostic criteria and symptoms across (fMRI) 24 lifespan: ADHD, Not Otherwise Specified 11; combined presentation 10–11; Generalized Anxiety Disorder 145, 153 Concentration Deficit Disorder 11–12; Greiner, A. 129 overview 5–7; predominantly hyperactive/ grief issues 61–2 impulsive presentation 7–8; predominantly grit, defined 97 inattentive presentation 8–10; Sluggish Group Cognitive Behavioral Therapy: Cognitive Tempo 11–12 approaches to 123; nonrandomized control Dialectical Behavior Therapy for Borderline studies on 123–6; psychosocial treatments Personality Disorder (DBT) 84, 124–5 129–30; randomized control studies on dopamine model of motivation 25–6 126–9; studies on 123–6 downward arrow technique 76–7, 176 guanfacine (Intuniv) 113, 115, 117, 131, 133 driving behaviors 8–9, 17–18, 29 gyrification 22 Dysfunctional Thought Record (DTR) 72 “Harold” clinical case example: assessment emerging adulthood issues 52 159–63; cognitive behavioral therapy 164–8; Emilsson, B. 128 overview 159; pharmacotherapy 163 emotional hijacking notion 97 Hesslinger, B. 124 emotional reasoning 74 t Hirvikoski, T. 128 environmental engineering 106–7 home packet for patients 26, 36 Downloaded by [New York University] at 12:14 14 August 2016 “escape behavior” 80, 84, 94–7, 141, 157, 171, 182 hyperfocus 9, 40, 91 etiologic models: default mode network 24–5; dopamine model of motivation 25–6; “Ian” clinical case example: assessment 144–6; executive dysfunction model 19–21; cognitive behavioral therapy 147–52; genetics 21–2; neuroimaging technology overview 144; pharmacotherapy 147 and 22–4; overview 18–19; reward- identical twins studies 21 deficiency model 26 if-then coping plans 53, 82 European Network Adult ADHD 131 imipramine 113 evidence-based treatment options 116–18 impetuous statements 10 executive dysfunction model: alternative to 25; implementation strategies: clinical case automatic thoughts and 99; behavioral examples 148, 157; in cognitive behavioral scripts and 79–80; intervention approach therapy 68; complicating factors 171, 178, 232 Index 180–1, 194; intervention categories 69, 97; Mitchell, K.J. 125, 127 introduction 2, xii; management of 109; modafanil 113, 114. 134 overview 81–4; use of 91, 98 Monoamine Oxidase (MAO) inhibitor 114 inattentive presentation 5–10 motivation: to change 62–3; as complicating inattentive symptoms 6–8, 10–11, 33, 125 factor 169–71; deficits in 5; dopamine individualized conceptualization based model of motivation 25–6; specific approach 59 interventions for 96–9 Intuniv 116, 133 “invisible fences” metaphor 100 National Comorbidity Survey-Replication 14 islands of competence 76 National Institute for Health and Clinical Excellence (NICE) 131 “Jason” clinical case example: assessment negative beliefs 56, 59, 76–8 153–5; cognitive behavioral therapy 156–9; negative self-evaluations 37, 56, 75–6 overview 152–3; pharmacotherapy 155–6 neurobiology: ADHD underpinnings 18–19, jumping to conclusions 74t 21–2, 26, 47; dopamine deficiencies 97; environment interaction 50–2, 51 t; genetic Kessler, R.C. 35 predispositions 196; medications and 124, 199 King, K.A. 130 neuroimaging technology 18–19, 22–4 Kofman, M.D. 125, 127 neuropsychological screening 36–8, 45, 138, Koydemir, S. 129 146, 154, 161 Niebuhr, Reinhold 58 labeling 72, 74 t nonverbal working memory 20 Langer, S. 129 learning impairments 36 opioid dependence 152, 153 life outcomes 3, 5, 15–18, 48, 60, 67 Oppositional Defiant Disorder (ODD) 16, “Linda” clinical case example: assessment 137–9; 42–3, 175–7 course of treatment 139–43; overview 136–7; Otto, M.W. 121 pharmacotherapy 143–4 overgeneralization 74t, 101, 184 Livesey, D. 126 lying behavior 144, 150, 172–5 panic disorder 4, 47 Patton, George S., Jr. 110 magical thinking 74 t, 175–7 Penn State Worry Questionnaire (PSWQ) 36 Magnetic Resonance Imaging (MRI) 22 Pervasive Developmental Disorder (PDD) 7, 43 magnification/minimization distortion 74 t, pessimistic thoughts 75, 100 101–2 pharmacotherapy: maintenance and follow-up maintenance and follow-up: cognitive 199–200; medication-related complications behavioral therapy 191–6; community 187–9; nonstimulant medications 132–4; support/psycho-education 197–8; coping phases of 190–1; research evidence for 131–4; strategies and resources 196–9; long-term stimulant medications 132; treatment with management 198–9; overview 190–1; 111–15, xiii pharmacotherapy 199–200; wrapping up physical/medical well-being 177–80 and booster sessions 194–5 point of performance 57, 68, 83, 94, 100, 171 maintenance stage of change 170–1 positive bias 58, 71, 74 t, 108, 192 Downloaded by [New York University] at 12:14 14 August 2016 maladaptive schema 54, 78 Positron Emission Tomography (PET) 24 Marks, D.J. 125, 127 Posttraumatic Stress Disorder (PTSD) 30 materials management 105–6 precontemplation stage of change 170 medication-related complications 187–9 predominantly hyperactive/impulsive melatonin production 107, 180 presentation 7–8, 10 mental hyperactivity 7–8 predominantly inattentive presentation 8–10, methylphenidate compounds 114–16, 132, 12, 125 143, 156 preparation stage of change 170 Meyers-Briggs Type Inventory 49 preschool functioning 27–8 mindful awareness 86, 97 presentation, defined 5 mindfulness-based approaches 84–5 presenteeism, defined 17 mind reading 74 t, 151 problem-focused therapy (PFT) 122–3 Index 233 problem management/decision making 107–10 self-advocacy 196–7 procrastination: avoidant behaviors 77, 93–4; self-diagnosed individuals 27 clinical case studies 141, 143, 145, 149–51, self-esteem: introduction 16; low self-esteem 156–7, 163, 1650166; complicating factors 137–8; maintenance of 73, 76, 130, 193; 179–81, 186; Daily To-Do List 87, 91; overview 99–102, 123–4, 126–7; role of 99 depression and 39–41; estimation of 102; self-monitoring 19, 73, 178, 181 impact of 44, 98–9; maintenance and self-report symptoms questionnaires 13–14 follow-up 195, 198; management of 96, Serenity Prayer (Niebuhr) 58 107–8, 110; negatively reinforcing 80–1, serotonin-norepinephrine reuptake inhibitors 84–5, 101–2; overview 11, 31; 10-minute (SNRIs) 114 rule for 95–6; treatment 49–51, 54, 55 t, 60, should statements 74t 63–4, 71, 77 sleep concerns 179–80 Prosecuting Attorney metaphor 71, 72 “sleep script” 180 psychiatric comorbidity 15–16, 117, 119 sleep-wake cycle disturbances 115, 153 psychiatric history 27, 29–30 Sluggish Cognitive Tempo (SCT) 6, 11–12 psycho-education: component of treatment smartphone daily planner 88 49–50, 63, 139, 146, 173; effectiveness of Social Learning Disorders (SLD) 43–4 123–4, 126–8; need for 36, 62, 122; overview Solanto, M.V. 88, 125, 127 63, 98, 197–8 specific interventions, for managing Adult psychosocial treatments: miscellaneous ADHD: attitudes, beliefs, self-esteem treatments 129–30; overview 5, 12; peer 99–102; coping skills 86–110, 102–3; Daily reviewed outcome studies 130 t; research Planner 89–90; data management 103–5; evidence for 118–19; summary 131; getting started 93–6; materials management treatment approach 48, 50, 59–60, 78; types 105–6; motivation, emotions, energy 96–9; of 116–17, xiii SQ4R strategy 105; time and task psychostimulants 12, 116, 133 management 90–3; To-Do List 86–9 SQ4R strategy 105, 143 Ramsay, J.R. 120 stages of change model 170 Reasoning and Rehabilitation for ADHD stay-at-home parents 29, 91, 137 Youths and Adults program 128 Stevenson, C.S. 126 reckless spending 10 Stevenson, R.J. 126 reconstitution 20 Structured Clinical Interview for DSM-IV reflexive actions (impulsivity) 57 (SCID) 30 relationship impairment 16–17 structured diagnostic interview 30–6 reverse engineering impairments 49, 64, 141, substance use/abuse 15, 16, 41–2, 47, 152–3 164, 173–4, 176 symptom checklists 32–4 reward deficiencies 5, 25–6, 78 syndromatic persistence 14 Robin, A.L. 43 Rostain, A.L. 120 technology issues 31–2, 180–2 rubric for prioritization 88 10-minute rule for procrastination 95–6 therapeutic alliance 65–7 Safren, S.A. 121 therapy-interfering behaviors 66, 171 Salakari, A. 126 time management: consequences 104; Daily Downloaded by [New York University] at 12:14 14 August 2016 scaffolding: academic scaffolding 29, 145; To-Do List 86–9, 91, 98, 139, 142, 147–8; benefits of 8, 162; for coping skills 68, 142, difficulties with 6, 9–10, 20, 123, 125; 182; Daily Planner and 89, 90; mental pessimistic thoughts 75; principles of 143; scaffolding 49, 68 treatment models 49, 57, 78, 126–7, 140, schemas see core beliefs 192; at work 44, 196; see also Daily Planner; schizophrenia 47 procrastination Schütz, A. 129 treatment goals: of cognitive behavioral selective abstraction 72, 74 t therapy 63–5; evidence-based treatment selective focus 51 options 116–18; functional impairments Selective Reminding Test (SRT) 37 46–8; pharmacotherapy 111–15, xiii; selective serotonin reuptake inhibitors psycho-education 49–50, 63, 139, 146, 173; (SSRI) 114 see also psychosocial treatments 234 Index tricyclic antidepressants 113–14, 117, 131, 134 Wasserstein, J. 125, 127 Tzelepis, A. 43 Wechsler Adult Intelligence Scale—Fourth Edition (WAIS-IV) 37 University of Pennsylvania Perelman School of Weiss, G. 122 Medicine 2, xii Weiss Functional Impairment Rating Scale US Department of Education 72 (WFIRS) 35 US Food and Drug Administration (FDA) 116 Whitmont, S. 126 Wilens, T.E. 120 verbal working memory 20 workplace 16–17, 44, 196 Virta, M. 122, 125–6, 129 World Health Organization 26 Vocabulary, Block Design, Digit Span, and Digit Symbol Coding subscales 37 Zametkin, A.J. 24 Downloaded by [New York University] at 12:14 14 August 2016