Cognitive-Behavioral Therapy

for Adult ADHD

Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical

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

J. Russell Ramsay, PhD, is cofounder and codirector of the Adult ADHD Treatment and
Research Program and an associate professor of clinical psychology in psychiatry in the
University of Pennsylvania’s Perelman School of Medicine. He is cochair of the profes-
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
Cognitive-Behavioral Therapy
for Adult ADHD
An Integrative Psychosocial
and Medical Approach

Second Edition

J. Russell Ramsay and Anthony L. Rostain

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
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.
This page intentionally left blank
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
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
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
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

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
Appendix 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 neurodevelop-
mental 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 repeat-
edly 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-
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 clin-
ical 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 dif-
ficulties 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 medi-
cation 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-
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 treat-
ment “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 defi-
cits 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 experi-
enced 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 essen-
tial 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
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 pharmaco-
logic outcome studies.
Chapter 4 focuses on presenting four new case examples with which we illustrate
commonly encountered presenting problems, assessment procedures, and our com-
bined treatment approach in action. We have chosen some of the more common pre-
senting 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 pharmaco-
therapy 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.
Acknowledgments

The authors wish to thank many individuals, without whom the development and com-
pletion 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 pub-
lic. 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
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 profes-
sionals 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 clini-
cians 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.
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 intel-
lectual companionship and professional advice were invaluable in fostering my devel-
opment 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 col-
leagues 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 tal-
ented therapist, a diligent and hardworking researcher, a remarkably intelligent thinker,
and one of the funniest people I know. His energy, enthusiasm, modesty, good nature,
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.
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 mar-
riage 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 com-
pleting 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 sup-
port and involvement. His path through college included often falling behind in his
work, dropping and retaking many courses, leading to his being on track to be graduated
when he is 25 years old. Watching the majority of his friends move on with their lives,
Ian came to the realization that he was going to be “old” by the time he finished and now
faces the more difficult upper-level courses required for his major, the combination of
which led him to succumb to his parents’ wish that he get evaluation.
JASON is nearing his 30th birthday. He had always been described as “on the go” as a
child and teenager. He was an average student throughout school, but his teachers often
commented that his work and study habits were inconsistent. He channeled his energy
into sports and was an accomplished athlete who never touched drugs or alcohol and
was thought to be on track for a scholarship to play lacrosse in college. However, a string
of serious injuries and surgeries derailed Jason’s athletic career. He got out of shape and
eventually became addicted to the pain medications he was prescribed for his injuries.
After stints in rehabilitation programs and other treatments, Jason was 9 months clean
and sober, but he was living at home with his parents and had no structure to his life
other than treatment appointments. Moreover, he seemed unable to follow through on
suggestions from his counselor to find a job, enroll in school, or find some other
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 chil-
dren. He has a long history of serial employment working in sales but has been unem-
ployed 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 acknowl-
edged 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 adult-
hood, 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 assess-
ment 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; there-
fore, we also emphasize implementation strategies to target the motivational and perfor-
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 obvi-
ous (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 spe-
cific 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 men-
tion 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 introduc-
ing 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 con-
tribute 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 chal-
lenges 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 observ-
ers, 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 psy-
chiatric 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 symp-
toms without adequately reviewing the relevant history of functioning and considering
alternative causes of problems. The very moniker “attention deficit” can be misleading.
Individuals with ADHD have the ability to pay attention to tasks that are interesting,
rewarding, or otherwise compelling in some way, though they struggle with the effortful
redirection and allocation of attention to less immediately salient tasks. These various
complications in the process of identifying ADHD has led to it being among the first
mentioned when discussions turn to controversial psychiatric diagnoses.
The symptoms of ADHD are particularly difficult to define because it is hard to draw
a dissecting line across a continuum of functioning to mark where normal levels of
behavior end and clinically significant difficulties begin. In psychology and psychiatry,
issues are usually measured by differences in degree rather than a clear demarcation line.
As Edmund Burke observed when considering the distinction between day and night,
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 identi-
fied 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 experi-
ences 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 play-
ing football until the broken bone heals; bed rest for the flu).
Clinical psychology and psychiatry are fields in which the diagnostic process is com-
plex 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 function-
ing” 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 exces-
sive “social” drinking become alcohol abuse?
The symptoms of ADHD are often difficult (though not impossible) to observe. The
characteristic features of ADHD can be present but not yet causing problems to the
degree that they are viewed as impairments. As has been noted elsewhere, ADHD can be
thought of as akin to the wind—one does not really “see” the wind, but rather observes
it in its effects, such as branches or loose papers moving in the breeze (Ramsay, 2010b).
However, there is an undeniable continuum of wind intensity from light breeze to gale
force winds. Moreover, the effects of the intensity of wind cannot be defined without
consideration of the context. Relatively strong winds can be well managed by, if not
beneficial to, someone piloting a sailboat; a stiff breeze, on the other hand, will be very
disruptive to a yard sale or outdoor art show.
There are contemporary scientific models for understanding ADHD that help to
increase its “visibility.” We and others contend that the “A” and the “H” in the ADHD
acronym are misleading insofar as they represent circumscribed and incomplete exam-
ples 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 under-
standing 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 diag-
nostic 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 remain-
ing 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 neu-
rodevelopmental 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, replac-
ing the previous 7-years-old age of onset criterion. There is no requirement that full
diagnostic criteria be met or that impairments necessarily are experienced by that age,
acknowledging the developmental course of the condition; rather, the purpose of the age
change is to recognize that full symptomatic expression and associated impairments
may occur after childhood or adolescence in many cases (Faraone et al., 2006; Polanczyk
et al., 2010). In fact, an evidence-based case can be made to set the threshold at 16 years
old (Barkley, Murphy, & Fischer, 2008).
Second, the term presentations replaces the use of types to identify that there are dif-
ferences 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, predomi-
nantly 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 diag-
nostic 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 disinhi-
bition, 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 com-
bined 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, dis-
organization, 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 profes-
sionals 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 symp-
toms 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 suf-
ficient 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 sepa-
rate set of diagnostic criteria for adult ADHD from those used for children and adoles-
cents. 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 rele-
vant 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
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, assess-
ment 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 ongo-
ing 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 “presenta-
tions” 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 presenta-
tion reflects the existence of behavioral disinhibition and impulsivity without the cogni-
tive 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 presenta-
tion), 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 emo-
tional and behavioral impairments in all stages of life than do individuals with the pre-
dominantly 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,
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 physi-
cal restlessness, such as bouncing their legs, playing with things with their hands, exces-
sive 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 inter-
fere 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, driv-
ing 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 con-
centration. 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 pre-
sentation (Wilens et al., 2002; Wilens et al., 2009). Even in cases of a combined presenta-
tion, 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 inat-
tentive 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 develop-
mentally appropriate expectations. Most individuals described “getting by” by using
strategies that do not work in adult life.
Adults with ADHD have disproportionate trouble resisting the lure of distracters that
offer immediate positive reinforcement (e.g., something enjoyable) or negative rein-
forcement (e.g., escaping a less compelling or distasteful task before them), or a combi-
nation. 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 adult-
hood, and the negative consequences associated with inattentiveness and disorganiza-
tion 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 indi-
viduals 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 noth-
ing 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 per-
formed. 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-
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 “pseudo-
efficiency,” 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 behav-
ioral 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 dif-
ficulties. 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 argu-
ment can be made about how to conceptualize the distinction better. Regardless, indi-
viduals 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
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), creat-
ing 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 hyperac-
tivity 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 disorganiza-
tion, 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 symp-
toms 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
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 encoun-
tered by and unique treatment needs of individuals with Sluggish Cognitive Tempo
(SCT) that might be better described as Concentration Deficit Disorder (CDD). In clini-
cal 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 con-
centration 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 psycho-
stimulants. 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

Many of the difficulties involved in establishing diagnostic criteria for ADHD also hin-
der efforts to accurately gauge the prevalence of ADHD—it is difficult to count some-
thing 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 preva-
lence 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 interna-
tional 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 variabil-
ity 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
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 diagnos-
tic 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 thresh-
olds (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 mea-
sures of impairments.
There have been many other studies examining the persistence of ADHD from child-
hood to adulthood. Although there are differences across studies in the definition of per-
sistence 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 symp-
toms 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 &
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 symp-
toms 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 docu-
mented 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 disor-
ders 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 prob-
lems (Barkley, 2006; Huntley et al., 2012; McGough et al., 2005; van Emmerik-van Oort-
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 com-
munity 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 dis-
order-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 dis-
order, 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 treat-
ment 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 assess-
ment 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
impairments in at least one major domain of functioning. When compared to adults with-
out ADHD, adults with ADHD consistently complete fewer years of school, have lower
levels of employment, earn lower salaries, change jobs more frequently, receive more nega-
tive 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 life-
long 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 achieve-
ment 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 asso-
ciated 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 sur-
vey of US workers, ADHD emerged as a significant predictor of overall lost work perfor-
mance. 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 psy-
chiatric 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
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 consid-
ering 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), includ-
ing 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 expe-
riences 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 dys-
function model of ADHD to which we have already referred.

Etiologic Models for ADHD

ADHD has strong genetic and neurobiological underpinnings. Research into the herita-
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 differ-
ences between the development and functioning of the brains of individuals with and
without ADHD. Studies have aimed at localizing functioning and, more specifically dys-
function, 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 cul-
tural 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 achiev-
ing the ultimate reward. As can be imagined, there are a number of coordinated behav-
iors involved in such a process and various metaphors have been employed to explain
the organizing role of the executive functions: central executive, coach, conductor, orga-
nizer, 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 succes-
sive self-directed behaviors building upon the existing foundation forged by those pre-
ceding them; thus, they function individually but most importantly collectively.
A foundational executive function involves the capacity for self-directed attention,
which allows for self-awareness and self-monitoring. This initial capacity allows an indi-
vidual 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 situ-
ation, 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, experi-
ence, 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 associ-
ated with nonverbal working memory.
The capacity for verbal working memory enables the privatization of speech or inter-
nal 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 emo-
tional states. Individuals learn to manage and modify their feelings, handle uncomfort-
able 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 solv-
ing. 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 prob-
lems 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 evolu-
tion-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
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 identi-
fied several key, semi-distinct variables: time management, organization/problem solv-
ing, 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 diag-
nostic criteria (Kessler et al., 2010).
We are convinced that the executive dysfunction model of ADHD provides a scien-
tifically 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 individ-
ual 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 con-
ditions. 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, indi-
cate adopted children with ADHD are significantly more similar to their biological par-
ents 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.
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 function-
ing 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, eventu-
ally 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
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 sur-
face 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 devel-
opment 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 func-
tioning (i.e., better vs. worse). The ADHD group exhibited a nonprogressive loss of vol-
ume 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 exhib-
ited 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 vol-
umes 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 adult-
hood (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 net-
works 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 find-
ing being smaller volumes of particular prefrontal brain regions as well as global cerebral
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 fre-
quently 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 infor-
mation and solve cognitive problems. For instance, the dorsal area of the anterior cingu-
late 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
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 vari-
ability of response. A parsimonious explanation for this finding is that ADHD individu-
als 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 poste-
rior 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 aver-
sion” 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, individu-
als 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 behav-
ioral 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 under-
standing 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
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 inter-
act 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 apprecia-
tion 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 sys-
tems 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 symp-
toms 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 publi-
cation 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 inter-
vening 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
(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 differ-
ent 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 evalua-
tion 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 prob-
lems 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 cir-
cumstances. 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 evalua-
tion 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 diffi-
culties, 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
often arise in the review of presenting problems, it is essential to take a systematic devel-
opmental 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 high-
lights about family functioning and relevant dynamics. We inquire about family medi-
cal, 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 symp-
toms. 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 psychiat-
ric 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, includ-
ing 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, mid-
dle 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
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 with-
out 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
or impulsivity. If there have been treatments for medical or psychiatric conditions,
including ADHD, inquire about past diagnoses and assessments, and response to previ-
ous treatments. In some cases, the clinical interview may unearth symptoms of a psychi-
atric 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 tick-
ets, 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 prob-
lems, or an EEG to rule out seizure disorder. Atypical presentation of “attention prob-
lems,” 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 neces-
sarily end up revealing sufficient evidence to support a diagnosis of ADHD. Other fac-
tors, 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 impor-
tant to help patients identify and get help for their difficulties. Thus, a structured diag-
nostic 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 dis-
orders (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 psychi-
atric 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 sec-
tion, 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 rep-
resent 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
not experienced the trauma, would they still have exhibited features of ADHD? The situ-
ation 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 pro-
file 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 developmen-
tal 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 symp-
toms 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 inefficien-
cies 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
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 concep-
tualized 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 mod-
ern 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, technol-
ogy 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-to-
day responsibilities, fulfill personal obligations, learn from mistakes and change behav-
iors, 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, cir-
cumscribed difficulties. Individuals with ADHD, on the other hand, often report
numerous and recurring examples of functional problems that cause them great suffer-
ing 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 check-
list 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 informa-
tion 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 symp-
toms (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-
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 indi-
viduals who manifest these symptoms, either distinct from a traditional ADHD presen-
tation 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 pres-
ence of DSM symptom criteria is a necessary but insufficient facet of a diagnostic assess-
ment 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 associ-
ated 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
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 atten-
tion, but also the ability to get started on work tasks, initiate and sustain attention, main-
tain 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 symp-
toms, 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 disor-
ders, 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 recom-
mend 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 disor-
der 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
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 persis-
tence 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 audi-
tory 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 exec-
utive 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 specifi-
cally 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 com-
pared 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, work-
place, 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
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 documen-
tation 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 func-
tioning 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 expe-
rienced 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 demoral-
ization. Patients rate each item as either true or false as it pertains to their current atti-
tude 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 mini-
mal (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
As part of our comprehensive assessment, we use a brief collection of neuropsychologi-
cal 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 evi-
dence that indicates the need for further psycho-educational assessment of learning
impairments, or neuropsychological assessment of more pronounced cognitive impair-
ments 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 min-
utes 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 sub-
scales 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 origi-
nally 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-
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 corre-
lates 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 formu-
lation 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 inter-
twined with various other developmental frustrations, emotional symptoms, and life
problems. Many individuals initially enter mental health treatment for depression or anxi-
ety 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 defin-
ing 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, sever-
ity, 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
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 associ-
ate with getting engaged in a task. Research examining the distinct association of dis-
torted 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 atten-
tion. 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 pro-
crastination and difficulty concentrating, symptoms of depression will magnify prob-
lems 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 expe-
rienced 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 devel-
ops as a result of repeated life frustrations and demoralization, or whether both disor-
ders 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 dif-
ficulty). Thus, patients with comorbid ADHD and depression may be significantly
underfunctioning or may have adopted a stoic attitude of “settling” for their circum-
stances, even if they express dissatisfaction with these circumstances.

Anxiety
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 associ-
ated 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 dif-
ficult 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 wor-
ries 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 anticipa-
tory 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 “brinks-
manship,” 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 emo-
tional 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 sub-
standard work based on this avoidance pattern.

Bipolar Disorder
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 symp-
toms 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
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 ongo-
ing substance abuse, there are many associated emotional, cognitive, and behavioral pat-
terns 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 impor-
tant to assess for substance use histories and current drug use during the initial evalua-
tion. 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 interest-
ing 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 depen-
dence requires treatment and stabilization (i.e., inpatient detoxification and rehabili-
tation 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
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 envi-
ronment with insufficient limits that ends up reinforcing oppositional behaviors pro-
vides 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 dys-
regulation, such as argumentativeness or “road rage” that contribute to presenting prob-
lems. 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 charac-
terized 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 oth-
ers for their difficulties and, correspondingly, minimize their personal influence on situ-
ations and their responsibility for making changes. The therapeutic agenda will likely
include issues related to anger/frustration management, dealing with interpersonal con-
flict, 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 diag-
nostic 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
led to previous identification. On the other hand, individuals with ADHD often experi-
ence difficulties in social functioning as a result of poor emotional regulation, impul-
siveness, 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 clini-
cian (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 his-
tory of social behaviors is absolutely essential in assessing potential social learning disor-
ders. In the course of gathering the educational history, inquiring about peer and teacher
relationships at each level of education, extracurricular activities or hobbies, and subse-
quent 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 impulsiv-
ity 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 pre-
sentation 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 pre-
sentations 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 man-
agement 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-
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 underestima-
tion because there continue to be no empirically based, consensually agreed upon diag-
nostic 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 environ-
mental factors over time. Its symptoms are associated with altered structure and func-
tioning 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 com-
prehensive diagnostic assessment. The core components of such an evaluation are a
review of presenting problems and current functioning; comprehensive history; struc-
tured diagnostic interview, to assess the presence of comorbid conditions or other con-
ditions 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 exec-
utive 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.
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 emerg-
ing 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 symp-
toms 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 treat-
ment, such as medication management. Other individuals might need medications to pro-
vide 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
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 cog-
nitions, behaviors, and emotions in understanding psychiatric disorders, with an empha-
sis 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 maladap-
tive 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 success-
fully 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 per-
sonal experience and are addressed through behavioral and cognitive methods, includ-
ing 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 crys-
tal 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 sys-
tems 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 interac-
tions. The contemporary CBT model does not maintain that thoughts and beliefs neces-
sarily 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
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 defi-
cits associated with ADHD and, therefore, represent an important domain for interven-
tion, one that also impacts behavioral (and emotional) management. Recent research
has identified that dysfunctional thoughts play a significant and distinct role in the func-
tional 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 pat-
terns 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 personal-
ized 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 conceptualiza-
tion that helps guide our psychosocial treatment approach.

Case Conceptualization
The CBT case conceptualization is the integrated understanding of the patient’s present-
ing 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 pro-
vides 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 uncom-
plicated 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
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 spe-
cific 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 scaf-
folding for understanding the source of their recurring coping difficulties. Once defined,
patients have a reference point for identifying their ADHD in action, which allows cop-
ing 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 procras-
tination. 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 con-
crete 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 asso-
ciated 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.
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 treat-
ment 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 emo-
tion were once alluded to in terms of “poor frustration tolerance” and as manifestations
of impulsivity. Recent conceptualizations, however, have shed new light on the disrup-
tive 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 manage-
ment of ADHD. Interventions addressing emotional dysregulation can now be consid-
ered 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 strat-
egies, manifestations of executive dysfunction) that are most salient to them. This con-
ceptualization 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 informa-
tion 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
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 con-
ceptualization 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 asso-
ciated 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 diag-
nosed until later in life, these effects likely play an influential role in situations and rela-
tionships 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 real-
ization 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 vari-
ety. Even when the recognition of differences occurs later in life, understanding past
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 experi-
ences 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 tempera-
ment and context (i.e., nature and nurture), has implications for one’s life course includ-
ing 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 impor-
tant 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 con-
ceptualization provides a framework for understanding the effects of ADHD on experi-
ences 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 moti-
vational 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-
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 nega-
tive. 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 dis-
covered 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 informa-
tive 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 iden-
tity. 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).
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 situa-
tions 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 asso-
ciated 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 identi-
fied 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 prom-
ised task to his to-do list (or does not regularly check that e-mail account) and subse-
quently 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 com-
mon compensatory strategy we have observed in adults with ADHD. Although it starts
as a manifestation of executive dysfunction, it is later magnified by maladaptive reac-
tions 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

• 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 prob-
lems 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
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, explain-
ing 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 sce-
nario, 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 pro-
fessor 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 sce-
nario 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 situa-
tions do you notice this difficulty? Does it remind you of similar difficulties you experi-
enced 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
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 con-
nected 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 behav-
ioral 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 func-
tioning. 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 function-
ing. 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 auto-
matic 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 impul-
sive behaviors, it is often the “after-the-fact” realization that one’s behavior was ill-
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 strug-
gles with time management and disorganization, forgot to pick up his wife’s dry clean-
ing, 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, second-
ary 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 encoun-
tered by adults with ADHD stem from executive dysfunction, their cognitive reactions
(and emotional reactions, by extension) play a role in their experiences and, subse-
quently, 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 con-
trol, 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 solv-
ing 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 acknowl-
edged 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
by defining a small, specific work task to do in order to get started, finding he got reason-
ably 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 prob-
lems 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 con-
ceptualization is usually clear-cut and uncomplicated, and CBT is devoted to imple-
menting 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 pic-
ture. Moreover, these factors will interfere with the follow-through required to face chal-
lenging 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.
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 concep-
tualization 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 plan-
ning, 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 sup-
porting 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 perfor-
mance than it is to taking a performance-enhancing drug. That is, exercise yields pro-
gressive 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 cop-
ing skills that represent the essential strategies for managing executive dysfunction asso-
ciated 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
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 strate-
gies, managing the various barriers to their use, and adapting them to different situa-
tions 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 conse-
quence 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 solu-
tion 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 fol-
lowed 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
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 explana-
tion 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 accep-
tance 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 deter-
mined 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 prob-
lems. 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 neces-
sary 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 recommenda-
tions. The clinical reality is that not all individuals who seek or are referred for an evalu-
ation 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
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, moti-
vation 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 treat-
ment (i.e., medications).
Spending time addressing these issues using motivational interviewing and motiva-
tional 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 symp-
toms, descriptions of ADHD they have heard from friends or the media, and about treat-
ment options.
To encourage further self-knowledge, we also encourage patients to engage in per-
sonal 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 per-
sonalized 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

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 likeli-
hood 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 study-
ing, 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 ther-
apy 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 com-
pensatory 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
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 nei-
ther 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 immedi-
ately 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 empha-
sized 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
The importance of the therapeutic relationship is ubiquitous in the psychotherapy lit-
erature (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 can-
not 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 thera-
peutic 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 under-
stand 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 encoun-
tered 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 dif-
ficulties 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 forgot-
ten, 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 out-
side of therapy. Indeed, these transference phenomena are highly prevalent. For exam-
ple, 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 par-
ticularly 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
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 thera-
pist’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 home-
work 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 produc-
tively 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 struc-
ture 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 poten-
tial 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
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 selec-
tion of behavioral targets for change. The review of specific contexts provides important
data about patients’ internal experiences, which may have connections with past devel-
opmental 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 devel-
oping 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 person-
ally 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 inhi-
bition) 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 enhance-
ment 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 situa-
tions 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
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 mov-
ing 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
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 inter-
ventions 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 inter-
pret 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
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 situa-
tions 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 state-
ment 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 relation-
ships, are associated with more negative experiences and accompanying aversive emo-
tions (including boredom). As a consequence, these associations paired with ongoing
executive dysfunction and motivational deficits make it harder to engage in various prior-
ity tasks and endeavors that are not immediately rewarding or compelling. Task avoid-
ance 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 manag-
ing 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 inter-
vention involves questioning the accuracy and/or utility of the automatic thought.
Reviewing the evidence for a thought may help identify potential distortions in the con-
clusions 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
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 indi-
vidual. 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 conse-
quence 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 gradu-
ated “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 one-
self based on comparisons with others (“I’m not a good student because I will not grad-
uate 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-
lematic situations and to draw connections between their thoughts, feelings, and out-
comes. 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 meta-
phors 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 unchal-
lenged, 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 reac-
tions, 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 cog-
nitive 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 com-
plete 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.
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 pro-
cesses, the therapist and patient should take time to complete a thought record dur-
ing 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
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 with-
out 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 distrac-
tions 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
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 treat-
ment are straightforward. There are many difficulties associated with executive dysfunc-
tion 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 repre-
sented 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 ado-
lescent 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 con-
trast, 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 mal-
adaptive beliefs usually requires both (1) an experiential component of assimilating
novel experiences that are incongruent with existing negative beliefs and (2) a cogni-
tive component of accommodating the belief system to account for these new experi-
ences. 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 pro-
cess 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
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 underly-
ing 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 finan-
cial 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 financial
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 first step?
J: I have to find a lot of these papers, though I generally try to shove most tax
papers into the same drawer in a filing cabinet. I guess I could open that drawer
and sort through the papers in there.
T: What is your automatic thought about taking that first 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 financially 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
handling things that are important.

As we can see, though procrastination is a common problem for ADHD adults, John’s
avoidant behaviors and incompetency beliefs reciprocally compound each other, result-
ing 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 procras-
tination 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, uncompli-
cated cases of ADHD may not exhibit maladaptive schema and CBT for these individu-
als 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’ engage-
ment 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 regula-
tion 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 assump-
tions, 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, conse-
quently, 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
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 reinforce-
ment difficult (Sonuga-Barke, 2011). Typically this involves applying positive reinforce-
ment 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 devel-
oped 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 rea-
sonable 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” behav-
ioral 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 televi-
sion, 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 play-
ing 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 unproduc-
tive 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 hall-
mark 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
the couch and watching television. Changing the behavioral script involves defining “tip-
ping 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 posi-
tive 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 rein-
forcement is particularly relevant for targeting escape behaviors that undergird procras-
tination 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 behav-
iors 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
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 inter-
ventions 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 rein-
forcement 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 func-
tion 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 enhance-
ment 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 recom-
mendations 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 obvi-
ous applications for adults. The motivational deficits associated with ADHD also require
consideration of ways to enhance follow-through. (We will use the term “implementa-
tion strategies” as an umbrella term for specific implementation intention strategies and
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 implementa-
tion 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 moti-
vation, 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 func-
tions (Gollwitzer & Oettingen, 2011). These strategies provide patients with mindsets
and tactics with which to handle the typical distractions and frustrations they encoun-
ter when using their coping strategies. Said differently, specific vulnerabilities stem-
ming 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 asso-
ciated 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 dis-
cussing these plans and rehearsing follow-through options to combat executive dys-
function 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 fol-
lowing through. In particular, it was difficult for him to initiate research on the availabil-
ity 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
whole Saturday ahead of me, and I will feel good about what I accomplished.”).
Implementation strategies further enable follow-through by anticipating and devel-
oping 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 quar-
terly tax payment paperwork appears confusing at first glance, does not require immedi-
ate 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 imple-
mentation 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 persis-
tence 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 associ-
ated 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
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 impor-
tant 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 tac-
tics cued by environmental factors that they become specific implementation strategies.
Moreover, these sorts of modifications and additions to the traditional CBT model char-
acterize 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 regula-
tion, which includes distress tolerance. More specifically, handling a degree of discom-
fort 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 avoid-
ance 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 uncom-
fortable 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
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 experi-
ences 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 objec-
tives. 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 treat-
ment 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 under-
standing of its manifestations are the first cognitive modification interventions in treat-
ment, 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 emo-
tions (including boredom), and cognitions related to self-recrimination and pessimism
that are highly disruptive to daily living and coping efforts. Even distractibility or prob-
lems 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, dis-
organization, 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 dif-
ficulties 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 prob-
lems are not magnified. The person with ADHD can notice and feel the frustration, but
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 discom-
fort. 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 mindful-
ness 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 improve-
ments 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 pur-
view of our objectives here.

Specific 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
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 founda-
tional 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 indi-
vidual. 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) iden-
tifying 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) refer-
ring 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 compre-
hensive 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 consid-
ered to be similar to an iTunes account that holds all media and apps. This comprehen-
sive 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 man-
aged 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 com-
prised 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 par-
ticularly associated with procrastination. A patient with ADHD noted that he had an
entry in his Comprehensive To-Do List titled “look into graduate schools” that is impor-
tant 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 commit-
ments 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, eas-
ily 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 recom-
mended 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 facili-
tates 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 adap-
tive 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 per-
form 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
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 impor-
tance 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 com-
plete, 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 prioritiza-
tion 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 usu-
ally 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, con-
sequently, 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 obliga-
tions 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 com-
mitment that it will be the central repository for the tasks, commitments, and other items
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 work-
ing 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 com-
mitments. Framing the commitment as an “honest” 10 minutes emphasizes the impor-
tance 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 week-
ends, 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 assign-
ments 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 exec-
utive functioning and motivational terms is more accurately understood as the organi-
zation 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 under-
standing 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 discom-
fort for adults with ADHD. In fact, many of them report the attitude that they do not like
feeling “bound” to a schedule, preferring instead to “go with the flow.” However, this out-
look 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 chil-
dren 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 ineffi-
ciencies 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 encour-
age people to err on the side of underscheduling rather than overscheduling at the out-
set. 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 overwhelm-
ing, 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 expecta-
tions (e.g., “I can keep going for 15 minutes more.”). Implementation strategies are used
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 extend-
ing 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, external-
ized 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 typi-
cal 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 sched-
ule? 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 aca-
demic 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-
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 per-
sonal 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 indi-
viduals 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 execut-
ing 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 impor-
tant 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 cog-
nitive 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.
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 undertak-
ings 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 procras-
tination, 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 empha-
sized 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, per-
haps 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 iden-
tify and anticipate the various barriers to task follow through and risks for procrastina-
tion 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.”).
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 antici-
pated difficulties along with minimization of reward or satisfaction. These cognitive dis-
tortions 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 inter-
ventions 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 behav-
ioral 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 televi-
sion, and walking to get one’s gym clothes may initiate the “launch sequence” for exer-
cise. 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 pro-
gressive 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
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 pro-
vide 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 sub-
sequently 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., implemen-
tation) 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 per-
mitted 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 rela-
tively 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 rein-
force off-task behavior. However, should they find themselves again mired in procrasti-
nation, 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
behaviors.

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, complet-
ing an academic degree program, or maintaining a household. These tasks require per-
sistence 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 pas-
sion 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 avail-
ability of dopamine in the “reward centers” of the midbrain that interfere with maintain-
ing 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 dis-
appointments 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 perva-
sive 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 reac-
tions 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 hijack-
ing” (or “amygdala hijacking”; Goleman, 1995) provides a way for patients to under-
stand 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-
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 behav-
ioral 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 imple-
mentation 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 execu-
tive 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 consid-
ered “recreational” or “pleasurable” tasks, patients often underestimate the degree of sat-
isfaction 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 manage-
ment” on task follow-through. Procrastination is wearying. One effect of procrastina-
tion 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 ade-
quately 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
when they know “no one is looking.” Externalizing reminders and motivational state-
ments can be helpful in terms of activating positive emotions and coping skills associ-
ated 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 obli-
gations 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 encoun-
ters 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 iden-
tifying 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 maladap-
tive 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
into the “event” for subsequent cognitions that magnify one’s reactions (e.g., “I’m sup-
posed 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 out-
looks, 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 bal-
anced 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 conse-
quence, 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 cog-
nitions 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 perfor-
mance. These metaphors represent cognitive interventions inasmuch as they present
alternative and adaptive frameworks for the management of a variety of situations. As
mentioned earlier, the metaphor of the Defense Attorney to help develop adaptive cog-
nitions 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, compara-
tive 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, rep-
resent good coping, and will likely help the adult with ADHD make progress toward per-
sonal 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 conse-
quences 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, circum-
scribed 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 treat-
ment. 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 per-
spective, 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 moti-
vational 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
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 likeli-
hood 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 deci-
sion 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 exam-
ples of ongoing coping difficulties and to minimize examples of improvement. This out-
look 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 associ-
ated 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 bet-
ter? 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 min-
utes 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-
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 myr-
iad 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 prepara-
tion, 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 exter-
nal 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 inten-
tion 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
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 infor-
mation 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 exam-
ple, 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 set-
ting 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 man-
agement 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 informa-
tion 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
to increase the likelihood of using the notebook. Moreover, simple communication strat-
egies 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 stu-
dents have somewhat different data management challenges. Students benefit from tak-
ing 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 stu-
dents 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 stu-
dent 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 sec-
tions. 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, includ-
ing 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 rehears-
ing and reviewing information helps to increase focus and comprehension.

Materials Management
In addition to difficulties managing conceptual information, adults with ADHD have dif-
ficulties 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 dis-
posal 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 per-
son 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 solu-
tion, 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 indi-
vidual 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-
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 asso-
ciated 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 personal-
ized 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 activi-
ties, 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 consid-
ering options to reduce them. Thus, a worker in a cubicle can seek out an empty confer-
ence 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 com-
puter tablet. Sometimes the solutions are as simple as closing a curtain over a window
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, deci-
sion making. We use the phrase problem management instead of problem solving to high-
light 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 consis-
tently 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) dis-
closing 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 differ-
ent 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 solu-
tions 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.
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’ neg-
ative 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 identi-
fied 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 spe-
cific 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 informa-
tion 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
are several choices that are deemed acceptable, and yet the individual does not have cri-
teria 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 per-
son “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 anxi-
ety, which can be difficult for adults with ADHD to manage, resulting in short-term
relief through procrastination about making a decision. Unfortunately, some opportu-
nities 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 imple-
mented 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 motiva-
tion 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 implemen-
tation in specific contexts will vary among individuals, and there will be different barri-
ers 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 con-
stellations. 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
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 straight-
forward undertaking, simply matching the correct medication at the right dose to treat
the symptoms described by patients. However, issues of compliance, side effects, toler-
ance, and psychiatric and medical comorbidity complicate the practice of pharmaco-
therapy, 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 medi-
cation 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 dur-
ing 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,
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 insta-
bility, or severe insomnia, we will discontinue stimulant medication. Milder side effects can
be addressed either via dose reduction or through the introduction of adjunctive medica-
tions (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

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 gastroin-
testinal side effects, and giving it at night minimizes the sedating effects. Unlike the stim-
ulants, 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 atomox-
etine, 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 med-
ications 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 bed-
time 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 hyperten-
sion, 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
agonists, we will try combining stimulants with alpha agonists, or stimulants with atom-
oxetine. 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 gen-
erally 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 car-
diac 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 diffi-
culty 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 sub-
jective 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 con-
centration or impulse control, we will start low-dose stimulant medication as an adjunc-
tive 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 circum-
stances, 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
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 intro-
ducing 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 medica-
tions 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
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 pharma-
cotherapy 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 treat-
ments. 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 estab-
lished 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 can-
not tolerate the side effects of the stimulants.
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 stud-
ied 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 medi-
cations 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 comor-
bid 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 prob-
lems, 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 symp-
toms provided by medications don’t always translate into satisfactory functional improve-
ments (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-
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 treat-
ments 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 integra-
tive 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) treat-
ment 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 treat-
ments 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
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 con-
trol 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 assign-
ment to the respective groups, there is the possibility that extratherapeutic factors influ-
enced 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 reac-
tions to stress. The following studies represent research on individual CBT approaches
for adult ADHD.

Open and Nonrandomized Studies of Individual CBT

Wilens et al. (1999) used a systematic chart review to study the effectiveness of an adapta-
tion 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 psychiat-
ric 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 medi-
cation 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 com-
pared with pretreatment scores. The combination of CBT and medications was associ-
ated 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 improve-
ment 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 previ-
ously cited clinical measures when compared with the point of medication stabilization.
Overall, 69% of the patients completing treatment had “much” to “very much” improve-
ment 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 com-
bined 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 function-
ing. Because the order of treatments was not controlled for, no conclusions regarding the
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 comor-
bidity, 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 indi-
viduals 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 pharmacother-
apy 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 experi-
encing 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 distracti-
bility (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 manage-
ment, n = 16) or continued medication management only (n = 15). Participants com-
pleting 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
symptoms despite medication treatment were randomly assigned to either CBT or relax-
ation-education treatment. Both treatment groups received 12 individual meetings of
50 minutes each, so all participants received equal exposure to treatment. Outcome mea-
sures 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 treat-
ment 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 com-
pared 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, hypno-
therapy, or wait list control group. The published study did not include the hypnother-
apy 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 neu-
rocognitive 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, dex-
troamphetamine, 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
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 mod-
ular 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 medica-
tions 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 treat-
ment 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 inves-
tigator 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 indi-
viduals with ADHD as well as mutual support in the coping process. The following stud-
ies 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
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 check-
list 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 long-
standing functional difficulties associated with ADHD might experience transitory low-
ered 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 ther-
apy (DBT) for borderline personality disorder (Linehan, 1993). The modified DBT
approach involves breaking down treatment for ADHD into 13 specific skill-based mod-
ules. 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, how-
ever, and all of them had started some form of medication treatment by that time, com-
promising 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 descend-
ing order. There were no changes in the medication management of ADHD in the treat-
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 neurobiol-
ogy as a discrete treatment module. Researchers are starting to investigate the effective-
ness 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 treat-
ment 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 + medi-
cation (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 behav-
ioral 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 inter-
vention approach were various areas of impairment associated with executive dysfunc-
tion, 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 signifi-
cant 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.
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 admin-
istered 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 con-
trols. 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 improve-
ments at the end of treatment in ADHD symptoms maintained most of these improve-
ments 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 function-
ing as being “somewhat” or “markedly improved” at follow-up compared with their pre-
treatment 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 depres-
sion, 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 ran-
domly 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: atten-
tion 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
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 symp-
tom 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 improve-
ments in self-esteem and anger.
Stevenson, Stevenson, and Whitmont (2003) conducted a follow-up randomized con-
trol 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, organiza-
tional 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 sig-
nificant 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 metacog-
nitive (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, organiza-
tion, and planning skills. In fact, the more severe the pretreatment ratings of inattention,
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 asso-
ciated 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 indepen-
dent ratings and self-reports of ADHD symptoms, impairments, and comborbidities.
The manualized group CBT program consisted of 15, twice-weekly sessions (90 min-
utes 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 con-
dition 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 antiso-
cial 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 dis-
cussed 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-
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 pro-
viding 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); comple-
tion 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 typi-
cally 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 fol-
lowed 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 asso-
ciated with adult ADHD may have some additional benefit.
Langer, Greiner, Koydemir, and Schütz (2013) evaluated a stress management pro-
gram 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 pro-
gram. 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”
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 ses-
sions. 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 sev-
eral 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 improve-
ments 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
• 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 impair-
ments 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 stron-
gest research support for its use: pharmacotherapy. We will review the empirical evi-
dence 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 medica-
tions 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
reviewers (Dodson, 2005; McBurnett & Weiss, 2011; Rostain, 2008; Santosh, Sattar, &
Canagaratnam, 2011; Volkow & Swanson, 2013) all recommend the use of stimulant medi-
cations (i.e., methylphenidate- or amphetamine-based compounds) as well as nonstimu-
lant 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 comor-
bid conditions), physical health, current and past medication use, treatment goals, and
patient preferences for medication effects and dosing patterns. In this section, we will pres-
ent 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 immedi-
ately 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 cer-
tain 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 methylphe-
nidate (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-
bility, mood instability, dysphoria, tics (involuntary movements), and harmful cardio-
vascular effects such as hypertension or cardiac arrhythmias. The onset of these
symptoms may warrant discontinuation of the medication. Fortunately, recent popula-
tion-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 atten-
tion 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 approxi-
mately 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, head-
ache, 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 psy-
chostimulants 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 reduc-
ing some of their adverse effects.
While immediate release preparations of guanfacine and clonidine have been avail-
able 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
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 ago-
nists 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 neuropsychologi-
cal 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, insom-
nia, 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 sero-
tonin to varying degrees, which result in improved attention span and impulse con-
trol 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, necessitat-
ing 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 con-
trolled 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 sero-
tonin reuptake inhibitors, stimulants and mood stabilizers), but given the current lim-
ited 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.

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, non-
stimulant 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 consid-
ered. 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.
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 cli-
nicians 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 exam-
ples of CBT for adult ADHD (see Ramsay, 2011a, 2012; Ramsay & Rostain, 2005d,
2008; Rosenfield, Ramsay, & Rostain, 2008). As with all our clinical examples pro-
vided throughout this book (and other publications), all case illustrations are com-
posed 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.

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 orga-
nization 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 hus-
band, 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.
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 inad-
equate 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 child-
hood 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 con-
sistent with her emotional “overreactions.” Linda’s performance on neuropsychological
screening measures indicated some evidence of executive dysfunction, mostly on mea-
sures 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-
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 expe-
riences 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 under-
standing 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.
Although usually identifying specific examples of coping difficulties before examining
cognitive processes, the therapist, who had conducted her evaluation, had heard evi-
dence 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 want-
ing to finish college. A first step we can take is to focus on using a Daily To-Do
List and Daily Planner to organize your tasks into specific 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 specific 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 pur-
poses 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 benefits I’ve had in life, I still can-
not 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 state-
ments 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 advan-
tages 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,
what had been dubbed her “typical” overreaction. These triggers activated what the ther-
apist hypothesized were schema related to inadequacy and self-mistrust. More specifi-
cally, 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 procrastina-
tion. 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.
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 dis-
comfort but still hit the ‘send’ button to accomplish the task.”). She also reminded her-
self 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 cop-
ing. 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, includ-
ing 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 pro-
cess 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 per-
form 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 suf-
ficient 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 enthu-
siasm 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.
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 concen-
tration difficulties in school and when reading required texts, Linda agreed to a medica-
tion 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 man-
age 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 sug-
gestions 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
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 han-
dling 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 com-
pleted 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 second-
ary 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
concerned with the amount of time he spent gaming and immersed in technology dur-
ing 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 disor-
der 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 com-
munity 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 cam-
pus 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 con-
cern 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
was general agreement between Ian’s and his parents’ ratings to indicate that he had
exhibited clinically significant symptoms of both hyperactivity/impulsivity and inatten-
tion during childhood that fulfilled diagnostic criteria for childhood ADHD. His mother
presented some old school report cards containing teacher comments about his behav-
iors 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 dif-
ficulties, 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 symp-
toms, 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 per-
sonal 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 ambiva-
lent about the diagnosis of ADHD, but when it was defined using an executive dysfunc-
tion model (e.g., “difficulties organizing behavior across time . . .”), he seemed much
more receptive to it; in fact, he said that this explanation was consistent with his recur-
ring 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 stimu-
lant 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 recom-
mended 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-
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 commit-
ment 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 prob-
lem solving (i.e., developing a sequence of specific steps), and the aforementioned cogni-
tions 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 sug-
gestion 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 sched-
uled, 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 plan-
ning 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 semes-
ter. He also acknowledged that it was not as bad as he anticipated it would be to run the
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 specifi-
cally, 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 spe-
cific, 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 appoint-
ments. 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 writ-
ing, 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 sim-
ply get them into narrative form during the initial drafts rather than editing himself as
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 oversleep-
ing, 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 rein-
forced 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 some-
one 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 ses-
sion, 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 uncom-
fortable 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 (includ-
ing 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 back-
ground 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 proj-
ect. 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
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 situa-
tion 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
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 situa-
tion, 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 over-
due 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 prob-
lem may reveal other problems of which they were not aware, akin to the cliché of avoid-
ing 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 com-
pleted 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
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 regi-
men of combined preparation of buprenorphine and naloxone for treating opioid crav-
ings 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 per-
formed some research and wondered if there was a connection between ADHD, sub-
stance use, and his current sense of being stuck.

Assessment
Jason’s parents participated throughout the evaluation process, both during the inter-
view and by completing observer reports of various inventories about their son’s func-
tioning 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 exhibit-
ing 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 par-
ents’ 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 fea-
tures seemed to represent ongoing frustrations and dissatisfactions with his current situ-
ation. 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 oppor-
tunity 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
setbacks. Finally, the possibility of bipolar disorder was thoroughly assessed, particularly
considering his substance use history, his dysfunctional sleep habits, and his fidgety pre-
sentation. Although notably restless, Jason did not exhibit any of the characteristic fea-
tures 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 emer-
gence 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 embar-
rassed 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
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 suf-
fered 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 his-
tory 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 con-
venient 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
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, buprenor-
phine, 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 evalu-
ating 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 daunt-
ing 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 treat-
ment. 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.
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 implementa-
tion 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, prob-
lems following through with exercise steps helped reveal the influence of his procrastina-
tion 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 sched-
ule 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
a variety of needs, including customer service, sales, and some other duties in his busi-
ness 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 ques-
tioned 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 mag-
nify 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 nega-
tive 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 opin-
ions 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
his confidence.
Jason and his therapist could not identify the specific day that it happened, but dur-
ing 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 inter-
view 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 chil-
dren. 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 thera-
pist 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 paper-
work 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 avail-
able slot. When Harold arrived for the rescheduled assessment, he was accompanied by
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 unem-
ployment was very difficult for him, both financially and from the loss of structure pro-
vided 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 non-
payment, 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 behav-
ior 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-
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 depres-
sive end of the continuum, not every day but more days than not. If anything, his pre-
sentation 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 func-
tioning; 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 inatten-
tive 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 hyper-
activity/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 dif-
ficulties 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 difficul-
ties 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
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 pro-
bation after the first semester, stating he had difficulties handling his newfound inde-
pendence 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 comput-
ers 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 com-
puter 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 manu-
als 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 fam-
ily grew, she was overwhelmed trying to keep up with their children’s academic and extra-
curricular 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
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, par-
ticularly 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 recom-
mended 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 disad-
vantages 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.
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 discon-
certing 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 con-
flict, 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 track-
ing 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
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 reti-
cent 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 com-
plaints 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 commit-
ting 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 cop-
ing 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
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 house-
hold 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 poten-
tial 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 with-
out 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 simi-
larly 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
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., think-
ing 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 contin-
ued 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 rein-
force 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 improve-
ments 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
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 sup-
port 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 unrealisti-
cally positive belief in “breaks.”
Harold’s case represents some of the challenges of complex adult ADHD and associ-
ated 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.
5 Complicating Factors

Findings from a range of clinical outcome studies indicate that cognitive behavioral ther-
apy (CBT) paired with pharmacotherapy will be helpful for most adults seeking treat-
ment 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 deliv-
ery 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 thera-
peutic 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
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 treat-
ment, 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 experi-
ence 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 help-
ful 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 contempla-
tion 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 anticontempla-
tion (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 iden-
tifying 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 rel-
evant 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 drop-
ping out of therapy, particularly in cases of ambivalence.
There are subsequent phases in the stage of change model through which individuals
may cycle several times, often simultaneously exhibiting characteristics of several differ-
ent stages. The preparation stage reflects efforts to implement some minimal behavioral
changes but without a commitment to making wholesale modifications. This is com-
monly 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 pat-
terns 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 dysfunc-
tion, motivational deficits, overlearned avoidant habits, and learned pessimism. Our
emphasis on motivational issues and the integration of implementation intention strat-
egies (Gawrilow & Gollwitzer, 2008) also overlaps nicely with and draws from the litera-
ture 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 per-
sonal “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 pro-
cess 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 respect-
ing 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.

Treatment Complicating Behaviors

The term therapy-interfering behaviors covers a range of behaviors that disrupt treat-
ment, 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, nonad-
herence 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 profes-
sionals commonly encounter distortions of information and rationalizations for behav-
iors in their daily clinical work. For our purposes, however, we will define lying as
intentionally withholding information or providing misinformation about issues rele-
vant 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 tech-
nology, 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 follow-
ing 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 distrac-
tion (e.g., pornography use), substance use, or self-initiated changes in prescribed medi-
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 treat-
ment offers a forum for understanding not only what happened, but also how it hap-
pened. 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, acknowl-
edging that CBT and other therapies rely on and require reasonable accuracy of informa-
tion 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-
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 col-
lege 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 oth-
erwise 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 under-
standably 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 decep-
tion 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 situa-
tion 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 dif-
ferent 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.
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 assign-
ment 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 text-
book 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 rationaliza-
tions 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 chil-
dren 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 man-
ifest 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 argumenta-
tive, as passive-aggressive, or as having a tendency to externalize blame for their difficul-
ties. 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 ambiva-
lent about the need for change, if not completely resistant to the notion. Motivational
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 thera-
pist 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 excep-
tions. 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 conceptual-
ization 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 difficul-
ties 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 man-
aging 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
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 jus-
tified, 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 accommoda-
tions 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 expecta-
tions 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 devel-
opment 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 under-
stand 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 mon-
itoring of behavior across time, it makes sense that adults with ADHD have greater dif-
ficulties 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-
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 challeng-
ing 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 encoun-
ter increased difficulties, which can be magnified by the emotional lability that accompa-
nies 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 persis-
tent 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 vulner-
able populations as it does in the general population. In fact, a hypothesis to be exam-
ined 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 pre-
scribed diet and exercise regimen to reduce cholesterol levels.
When the behavioral target involves the administration of a medication, or the avail-
ability 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
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 condi-
tion, 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 therapeu-
tic 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 particu-
larly 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 walk-
ing 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 engage-
ment task which greatly increases the likelihood of follow-through. Predicting difficul-
ties 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 anticipat-
ing how a plan will have to be adapted to different situations, such as adjusting a work-
out 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
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 pat-
tern 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 nega-
tive 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 modi-
fication and implementation plans. In most cases even cursory motivational enhance-
ment 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 eventu-
ally 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 coun-
ter 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.
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 technol-
ogy 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 perfor-
mance 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 differ-
entiated 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
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 tem-
plate 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 iden-
tify 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 reinforce-
ment 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 rein-
forced). That is, patients often underestimate the positive feelings associated with get-
ting 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 normal-
ize 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 main-
taining 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
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 associ-
ated 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 pat-
terns and to adjust their demeanor with patients, often while seeking regular consulta-
tions 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 ear-
lier, 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, oth-
ers 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-
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, review-
ing 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 cli-
nician 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, clini-
cians 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
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 infor-
mation, 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.

Significant 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 indi-
viduals 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 treat-
ment 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 prob-
lems 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 pop-
ulation 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 appar-
ent 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 depen-
dence or a mood disorder with suicide risk. Even when adult ADHD is accurately identi-
fied 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
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 treat-
ment 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 reac-
tions from what needs to be done to address the problem. In fact, this step often pro-
duces 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 subse-
quent 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 unemploy-
ment 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 embar-
rassment 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” assump-
tion 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
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 attor-
ney to provide guidance for significant financial difficulties or a tax audit. Legal repre-
sentation 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 compli-
cates 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 therapeu-
tic and/or support services with which to manage the problems at hand. Creating realis-
tic 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 pro-
vide. 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
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 medica-
tion 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 dif-
ferent 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 medi-
cation.” 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 reac-
tion 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-
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 nonadher-
ence rates ranged from 15–87% (Adler & Nierenberg, 2010; Ahmed & Aslani, 2013). The
take home message, however, is that nondherence to medication treatment is very com-
mon 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 medica-
tions’ 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 identi-
fied, the patient can examine their motives for skipping doses and can take more respon-
sibility 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 inap-
propriate 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 bupro-
pion, this can be achieved relatively quickly (within a few days). Alpha2 adrenergic ago-
nists 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
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 symp-
toms 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 diffi-
culty for patients and clinicians, alike. We have described some of the complicating fac-
tors 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 mainte-
nance 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.
Both CBT and pharmacotherapy progress through different phases as patients make
therapeutic progress and learn to independently manage their symptoms and take con-
trol 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 strat-
egies 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 medica-
tion 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 docu-
ment 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 medi-
cal 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 effec-
tive 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
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 ingre-
dient in pharmacotherapy is the pharmacologic agent whereas the active ingredient in
CBT is the ability to recognize and modify automatic cognitive, behavioral, and emo-
tional 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 psy-
chosocial 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 repre-
sent 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 fol-
low-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 observa-
tions 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
sustained changes before others’ perceptions of the individual with ADHD change.
Thus, a person with ADHD makes objective improvements in the number of days dur-
ing 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 dif-
ficulty 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 chal-
lenges, 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 dis-
continue 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 assess-
ments, 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 con-
trol 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 cop-
ing strategies to manage situations and determine a course of action. Throughout treat-
ment, 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 han-
dled 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 for-
getting to use effective coping strategies. Thus, rather than viewing such unavoidable slip-
ups 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 situa-
tion? What can I do to handle it and to minimize its occurrence?”). This harkens back to
our notion that CBT for adult ADHD provides a framework for understanding how dif-
ficulties 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 strate-
gies 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 high-
light 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 mes-
sage 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 ses-
sions 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 imple-
mentation 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-
cussed and sat down at lunch on Monday and planned the rest of my day.”). The schedul-
ing 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, rein-
forcing 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 mainte-
nance phase. Sessions primarily focus on fine tuning the use of coping strategies, draw-
ing 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 treat-
ment gains and prospective problem management of future issues and long-range cop-
ing. 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 meet-
ings 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 adjust-
ment 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,
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 spe-
cific terms and setting out realistic expectations for outcomes (e.g., “organize and imple-
ment 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 adoles-
cents, 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 treat-
ments, 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 adjust-
ment 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 neuro-
biological 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 responsi-
bility 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;
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 set-
tings. 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 instruc-
tor 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” experi-
ment 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 supervi-
sor 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 iden-
tify 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 accom-
modating 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 con-
sider the request and provide his or her answer, which is out of the patient’s control.

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 ongo-
ing 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 opportu-
nity 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 pre-
scribed 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 com-
mon 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 drink-
ing 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 manage-
ment of ADHD involves making informed decisions about various external aspects of
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 back-
log 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 differ-
ent 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 exec-
utive 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 man-
agement 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 manage-
ment, 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 cou-
pled 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 con-
tribute 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 deci-
sion 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 con-
tinuing 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
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 anal-
ogy 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 con-
ditions 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 indi-
viduals 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 deci-
sion 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 comor-
bid 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 pre-
scribed 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 treat-
ment 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
Managing the effects of ADHD is an ongoing proposition. It is a chronic, neurodevelop-
mental 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 man-
age 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-
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 facili-
tate 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 assess-
ment. 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.

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 execu-
tive dysfunction. New York: Guilford.
• Weiss, M. D. (2008). A manual for problem focused therapy of attention-deficit hyper-
activity disorder in adults. Unpublished manuscript.
• Young, S., & Bramham, J. (2012). Cognitive-behavioural therapy for ADHD in adoles-
cents and adults: A psychological guide to practice (2nd ed.). West Sussex, England:
Wiley.
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 implementa-
tion 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 pat-
terns in order to improve coping and functioning.
Appendix C
Outline of a 20-Session/6-Month
Course of CBT for Adult ADHD

• Session 1 (Getting Started)

Develop and define treatment objectives (“start small”)
Elicit highly specific 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 difficulties
(Even if the homework task is not completed or only partially attempted, it pro-
vides examples of the difficulties 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 difficulties
Address relevant interaction of comorbid problems and ADHD
• 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 difficulties
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 difficulties
Schema revision
Continued focus on “doing what works”
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
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)
(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
on applesauce and
swallow without
chewing beads

*FDA approval for adult ADHD.

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