Attention Deficit Hyperactivity Disorder: Treating Adult

• ADHD is a neurobiological disorder that is characterized -in adults- by inattentiveness and executive functioning difficulties (i.e., organization, planning, and impulsiveness; Wadsworth & Harper, 2007)
• Adults seeking counseling services most frequently report symptoms of inattentiveness. Brown (2005) reported that adults with ADHD have difficulties in six areas:
      1. Diminished ability to organize and prioritize and a lack of motivation
      2. Difficulty in focusing and maintaining attention
      3. Reduced concentration, marked distractibility, and difficulty in maintaining a sustained effort
      4. Diminished self-control of emotions and diminished tolerance of frustration
      5. Diminished verbal working memory (e.g., forgetfulness)
      6. Diminished capacity to inhibit behavior

Resource: National Resource Center on ADHD http://www.help4adhd.org/

Prevalence
The estimated prevalence of ADHD is 4.4% of the adult population (about 8 million adults) in the United States; the majority of adults go untreated (Kessler et al., 2006). Increasing age is correlated with improvement in informant ratings of ADHD symptoms and slight improvement in neuropsychological functioning; however the subjective experience of inattention appears to worsen with age (Bramham et al., 2012).

Identification/Assessment Strategies

Adults may initially present with co-morbid disorders including low self-esteem, anger control difficulties, chronic tardiness, substance abuse, difficulty with concentration, mood swings, or depression. It is estimated that 70% of adults with ADHD have a comorbid psychiatric disorder of conduct, mood, or anxiety (Wilens, Biederman, & Spencer, 2002), and as such possible co-morbid issues should be assessed.

An adult must have symptoms that began in childhood and persist into adulthood to be diagnosed with ADHD (National Institute of Mental Health [NIMH], 2008).

Self and Other Report Assessments
There are over 14 self and other report scales for the identification of ADHD in adults. The following three instruments are selected to illustrate the nature of methods commonly employed by counselors to identify ADHD among adults. Counselors are urged to consult references such as the Mental Measurement Yearbook and reviews (e.g., Davidson, 2008; Taylor, Deb, & Unwin, 2011) for detailed psychometric information regarding assessment tools for adult ADHD.

Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID)
The CAADID (Conners, Epstein, & Johnson, 2001) is a two part structured interview. Part 1 can be completed through an interview or by self-report of the client. Part 1 focuses on childhood and adult factors such as demographics, academics, occupation, and mental health. Part 2 is completed through an interview. Part 2 focuses on four DSM-IV criteria for ADHD including symptoms of inattentiveness / hyperactivity, age of onset, pervasiveness, and severity. Items are scored as present or not present and a scoring algorithm allows the counselor to make a diagnosis of ADHD based on DSM-IV criteria. The publisher (Pearson) indicates that the CAARS is a level B test, meaning that master’s level counselors who have had a course in appraisal are qualified to use it.

Conners Adult ADHD Rating Scales (CAARS)
The CAARS (Conners, Erhardt, & Sparrow, 1999) includes self-report forms (long and short versions), observer rating scales (long and short versions), and self-report and observer screening tools. The CAARS can be administered individually or in a group format. Eight scales reflect Inattention/Memory Problems; Hyperactivity/Restlessness; Impulsivity/Emotional Labiality; Problems with Self-Concept; Inattentive symptoms consistent with DSM-IV; Hyperactive-Impulsive symptoms consistent with DSM-IV; Total ADHD symptoms consistent with DSM-IV; ADHD Index; Inconsistency Index. The publisher (Pearson) indicates that the CAARS is a level B test, meaning that master’s level counselors who have had a course in appraisal are qualified to use it.

Wender-Utah Rating Scale (WURS)
The WURS (Ward, Wender, & Reimherr, 1993) consists of 25 items that correspond to childhood symptoms of ADHD which the respondent rates as descriptive of his or her childhood. The scale scores range from 0 to 100, at the selected cut off point of 46 or higher the scale correctly differentiated adult with ADHD, adult with a diagnosis of depression, and adults with no diagnoses. The rating scale has been used as a measure of medication treatment outcomes among adults with ADHD. The WURS is widely available through electronic means in multiple languages and there are no publisher restrictions on use.

Neuropsychological Testing and Assessment
Neuropsychological testing of attention capabilities and executive functioning is beneficial for the assessment of ADHD when it is used in conjunction with history, rating scales, and observation of current functioning. Evaluation of visual attention and response inhibition (e.g., Stroops tasks) and evaluation of attention lapses, vigilance, and response inhibition (continuous performance tasks) are able to distinguish between adults with ADHD and adults without ADHD (Davidson, 2008). However, adults with ADHD have inconsistent attention and inconsistent performance on neuropsychological tasks and thus a pattern of behavior across multiple measures is a more valid and reliable diagnostic indicator of ADHD among adults than interpretation of single instance scores (Woods, Lovejoy, & Ball, 2002).

Resource: Assessing adults with ADHD and comorbidities http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660162/

Intervention Strategies

The treatment of ADHD among adults includes stimulant drugs or other medications, cognitive behavioral therapy and relationship therapy, and treatment of co-morbid conditions. Interventions to improve medication compliance are particularly important for the successful long-term treatment of adult ADHD. While medication in combination with education and psychotherapy is a focus of clinical trials, alternatives including biofeedback, nutritional supplements, dietary changes, and perceptual/stimulation training may be treatments of choice for some adults (Spetie & Arnold, 2010).

Medication
Pharmacology intervention is aimed at reducing symptoms and minimizing effects of ADHD. Compliance with medication is a significant positive correlate of successful management of ADHD among adults (Safren, Duran, Yovel, Perlman, & Sprich, 2007). However, Perwien, Hall, Swensen and Swindle (2004) noted that medication compliance rates among adults with ADHD decrease after the first 2 months of treatment. Not all medications approved for the treatment of ADHD in children are FDA approved for the treatment of ADHD among adults (NIMH, 2008).

Stimulant medications are often the treatment of choice for addressing ADHD symptoms (Spencer et al., 1996). Methylphenidate and amphetamine are effective in improving the attention and concentration of adults with ADHD (Advokat, 2010). However, approximately 30% of adults are unable to tolerate, or do not respond to, stimulant treatment. In addition, stimulant medication may not be appropriate for use with persons at risk to misuse or abuse medication. Stimulant medications are available in both short (4 hours) and long acting (6-12 hours) formulas.

Antidepressants medications (i.e., brupropion, venlafaxine, desipramine, atomoxetine) are also effective treatments for ADHD in adults (Maidment, 2003). Some studies have reported that antihypertensive medication (e.g., clonidine, guanfacine) may reduce ADHD symptoms in adults (Davidson, 2008).

Counseling
Counseling interventions in conjunction with medication are an important part of the treatment of ADHD among adults. Psychotherapy alone is insufficient treatment for many adults with ADHD and medications alone do not lead to improvement in skills necessary for daily functioning (e.g., organization; Advokat, 2010).

Psycho Education
Psycho-education about ADHD, its causes, symptoms, and treatment options is an important starting point of all treatments for adults with ADHD (Rostain & Ramsay, 2006). Adults benefit from learning about the disorder and how the symptoms uniquely impact their lives (van Lammeren & Bruggeman, 2010). Education can help individuals develop individual treatment plans and empower medication ad- herence (Murphy, 2005).

Educational activities that may improve daily functioning of the adult diagnosed with ADHD include learning to organize, manage time, making lists of tasks, minimizing distractions, using a personal digital assistant, filing information, and adhering to a routine (Barkley, 2006).

Cognitive Behavioral Therapy
Cognitive Behavioral Therapy for adults with ADHD focuses on changing the negative beliefs clients may have about themselves and the world (Rostain & Ramsay, 2006). Years of undiagnosed ADHD may con- tribute to low self-esteem, and receiving a diagnosis may help adults address symptoms more effectively (NIMH, 2008). Although controlled trials are lacking, preliminary evidence suggests that CBT in combination with medication is an effective treatment strategy (Davidson, 2008; McDermott, 2010). Cognitive behavioral therapy can assist adults in creating enduring patterns of change that address the executive functioning deficits that are a hallmark of ADHD among adults (Solanto, 2011). Elements of Dialectic Behavioral Therapy (DBT) may assist adults with ADHD with self-awareness, toleration of behavior, regulation of emotions, and interpersonal problems (Hirvikoski et al., 2011; Philipsen, Richter, Metthies, & Hesslinger, 2010).

Relationship Counseling
Problems linked to ADHD, such as poor listening, forgetfulness, lack of organization, and co-morbid emotional problems can contribute to relationship stress. Family and relationship counseling can deepen a partner’s understanding that damage to a relationship from ADHD symptoms (e.g., inattention and lack of planning) are not willful and do not suggest a lack of caring or commitment to the partner (Murphy, 2005). Partners and family members can play a beneficial role in treatment, and an understanding of the disorder can improve communication (Lukens & McFarlane, 2004).

Resources:
Children and Adults with Attention Deficit/Hyperactivity Disorder http://www.chadd.org/

National Institutes of Mental Health http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/can-adults-have-adhd.shtml 
http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/complete-index.shtml

National Institute of Neurological Disorders and Stroke http://www.ninds.nih.gov/disorders/adhd/adhd.htm#Clinical_trials

National Resource Center on ADHD http://www.help4adhd.org/

Conners, C. K., Epstein, J., & Johnson, D. (2001). Connors’ adult ADHD diagnostic interview for DSM-IV. North Tonawanda, NY: Multi-Health Systems.

Conners, C. K., Erhardt, D, & Sparrow, E. (1999). Conners’ adult ADHD rating scales. North Tonawanda, NY: Multi-Health Systems.

Davidson, M. A. (2008). Literature Review: ADHD in Adults: A review of the literature. Journal of Atten- tion Disorders, 11, 628-641. doi:10.1177/1087054707310878

Hirvikoski, T., Waaler, E., Alfredsson, J., Pihlgren, C. Holmstrom, A., Johnson, A,…Nordstőm, A. L. (2011). Reduced ADHD symptoms in adults after structured skills training group: Results from a ran- domized controlled trial. Behaviour Research and Therapy, 49, 175-185. doi:110.1016/j.brat.2011.01.001

Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Connors, C.K., Demler, O.,… Zaslavsky, A. L. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbid- ity Study Replication. American Journal of Psychiatry, 163, 716-723. doi:10.1176/appi.ajp.163.4.716

Lukens E. P., & McFarlane W. R. (2004). Psychoeducation as evidence-based practice: considerations for practice, research and policy. In: A. R. Roberts & K. R.Yeager (Eds.), Foundations of Evidence-Based Social Work Practice (pp. 214–319). New York: Oxford University Press.

Maidment, I. D. (2003). The use of antidepressants to treat attention deficit hyperactivity disorder in adults. Journal of Psychopharmacology,17, 332-336. doi:10.1177/02698811030173016

McDermott, S. P. (2010) Clinical application of research on cognitive-behavioral therapies for adults with ADHD. In J. K. Buitelaar, C. C. Kan, & P. Asherson (Eds.). ADHD in Adults: Characterization, Diagnosis, and Treatment (pp. 254-270). Cambridge, GBR: Cambridge University Press.

Murphy, K. (2005). Psychosocial treatments for ADHD in teens and adults: A practice-friendly review. Journal of Clinical Psychology, 61, 607-619. doi:10.1002/jclp.20123

National Institute of Mental Health (2008). Attention deficit hyperactivity disorder. NIH Publication 08-3572. Retrieved from http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/adhd_booklet.pdf

Perwien, A., Hall, J., Swensen, A., & Swindle, R. (2004). Stimulant treatment patterns and compliance in children and adults with newly treated attention-deficit/hyperactivity disorder. Journal of Managed Care Pharmacy, 10, 122-129.

Philipsen, A., Richter, H., Metthies, S., & Hesslinger, B. (2010). Psychotherapy in Adult Attention-Deficit Disorder. In W. Retz & R. G. Klein (Eds.), Attention-Deficit Hyperactivity Disorder (ADHD) in adults: Key issues in mental health (pp. 159–173). Basel, CHE: Karger Publishers.

Rostain, A. L., & Ramsay, J. R. (2006). A combined treatment approach for adults with ADHD—Results of an open study of 43 patients. Journal of Attention Disorders, 10, 150-159. doi:10.1177/1087054706288110