Counseling Boys and Men with ADHD

George Kapalka

• Publisher: Routledge
• Year: 2010
• Print ISBN: 9780415993449
• eBook ISBN: 9781135849672
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Attention-deficit hyperactivity disorder primarily affects boys and male teens, and the symptoms can continue on into adulthood. Consequently, clinicians need to be well-versed in techniques to treat this disorder that are tailored specifically to the needs of males; there are, however, few resources available to them. This guidebook provides a review of the counseling, educational, and medical interventions that can benefit boys and men with ADHD. Kapalka begins with a review of symptoms, etiology, assessment, and diagnosis and then discusses a variety of specific interventions: individual counseling, parenting techniques, classroom interventions, and group counseling techniques. The use of medication in conjunction with counseling is also considered. Throughout all of the topics covered, Kapalka emphasizes what it is like to be male and have ADHD and describes the impacts that masculinity and gender expectations can have on the expression of and response to the disorder.

SECTION

1

Etiology, Epidemiology, and Course

CHAPTER

1

Symptoms of ADHD

In 1885, a German physician named Heinrich Hoffman wrote about some interesting patients that he saw in his practice, including the case of “Fidgety Phil,” which he found particularly intriguing (Stewart, 1970). This description is commonly regarded as the first important reference to a boy with hyperactivity. Because Phil could not remain still for any significant period of time, he exhibited significant management difficulties and proved to be very frustrating to those who came in contact with him. Since that time, hyperactivity has been considered to be among the most common, and troubling, behavioral symptoms of childhood.

In addition, since the early 20th century, physicians have also recognized that some children (especially boys) exhibit significant problems with being able to sustain attention. Still (1902) described some three dozen children (the boys outnumbered the girls by a factor of about 3 to 1) he encountered who had significant difficulties with maintaining focus and who also exhibited symptoms of notable overactivity. These two dimensions of symptoms were accompanied by problems with aggression, defiance, and emotional overreactivity. Thus, for over 100 years, we have recognized that children who exhibit problems with overactivity and difficulties sustaining attention present with significant emotional and behavioral difficulties and that these problems are evident mostly in boys.

The syndrome we know today as attention deficit/hyperactivity disorder (ADHD) has been known through a variety of terms. Still (1902) remarked that children with this syndrome exhibit a major “defect in moral control.” In the 1920s, these symptoms were presumed to be secondary to “postencephalitic” behavior disorder (Ebaugh, 1923), because children previously infected with encephalitis were noted to be particularly likely to exhibit these problems. This label eventually morphed into “minimal brain damage,” because brain damage due to known or unknown causes was presumed to be responsible for the symptoms. As it became evident that brain damage may not necessarily underlie the syndrome, the term was then replaced by “minimal brain dysfunction” and eventually “hyperkinetic impulse disorder” (Laufer, Denhoff, & Solomons, 1957). Gradually, as the diagnostic terminology continued to move away from presumed etiology to terms that are simply descriptive of the symptoms, in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association [APA], 1980), the term “attention deficit disorder” was officially approved, and the diagnosis specified whether a particular person exhibited a variant with or without hyperactivity. The fourth edition (DSM-IV; APA, 1994), introduced the comprehensive term “attention deficit/hyperactivity disorder,” a moniker that continues to be the official name of the syndrome at this time.

To diagnose ADHD per DSM-IV requirements, clinicians assess two dimensions of symptoms: hyperactivity/impulsivity and inattention. Depending on the specific variant evident in a given person, ADHD can be diagnosed as “predominantly hyperactive-impulsive type,” “predominantly inattentive type,” or “combined type.” Individuals who present with enough symptoms from either (or both) clusters to negatively affect their adaptive functioning but not enough symptoms to meet all diagnostic criteria in either cluster can be diagnosed with ADHD “not otherwise specified.”

Although the diagnosis of ADHD requires symptoms of the disorder to be present in a person before age 7 (APA, 2000, p. 92), there is no presumption in the diagnostic system about whether the symptoms remain into adulthood. The epidemiology and course of ADHD are discussed in more detail in the next chapter, but for now it must be noted that there is a significant number of boys with ADHD who do not “grow out” of the disorder and who continue to exhibit symptoms long after becoming adult men. These symptoms then become apparent in the course of usual adult lifestyle, including the workplace, intimate relationships, social adjustment, and so on. Thus, when reviewing symptoms of ADHD, one must consider the symptoms that are usually evident not only in childhood and adolescence but also in adulthood.

Boys, male teens, and men with ADHD commonly exhibit a variety of problems across different settings. In accordance with the DSMIV-TR diagnostic guidelines, these symptoms fall along the dimensions of hyperactivity/impulsivity and inattentiveness, and they are often referred to as the “primary” or “core” symptoms, because they are presumed to be directly caused by the underlying etiology. A boy with ADHD, however, is a member of his family, his class, and his peer group, and his interactions with his parents, siblings, teachers, and peers are negatively affected by the core symptoms. Similarly, a man with ADHD is also a member of his peer group, his own family (which now usually includes both the current spouse and children and the continued relationship with his family of origin), and the workplace. In these settings, boys and men with ADHD commonly develop secondary symptoms that stem out of the primary difficulties and further exacerbate their difficulties with adaptive behaviors. Thus, any comprehensive discussion of the symptoms of ADHD must take into account both primary and secondary symptoms, across many settings, and must consider various age groups across which symptoms may be apparent.

CORE SYMPTOMS

Boys and men with ADHD exhibit difficulties along two behavioral dimensions: those of hyperactivity/impulsivity and distractibility. These are presumed to be separate clusters, and impairment in at least one of them is required for diagnosis, but patients sometimes exhibit symptoms that overlap and may fall into either cluster. In addition, various settings where symptoms are apparent must be reviewed, because symptoms in each cluster may present differently in diverse settings and situations. Various age groups must also be considered, because the presentation of symptoms from each category commonly changes with age.

Hyperactivity/Impulsivity

Many boys and men with ADHD exhibit impulsivity, but sometimes these symptoms may, at first glance, be overlooked. Individuals with ADHD often act with little forethought, exhibiting a knee-jerk reactivity to environmental events. The experience of an urge is universal. We all feel urges and impulses to do things and say things. When our ability to control these impulses is intact, we are able to process an urge and evaluate the consequences of our behaviors before we decide how to act or what to say. An impulsive individual, however, converts an impulse into action with limited cognitive processing. Thus, boys and men who are impulsive often say and do things that, in retrospect, they recognize they should not have done or said. For them, controlling their urges to say and do things is a major struggle.

Many boys who are impulsive are also hyperactive. Hyperactive boys usually exhibit a “driven by a motor” quality, a restlessness, and a need to constantly move about. Impulsivity and hyperactivity are closely related. Human beings constantly experience urges of various types. Some of these urges are impulses to say something, and others are impulses to move or do something. Those boys who have difficulties suppressing their urges to move are described as hyperactive. Thus, hyperactivity is one expression of the larger problem: a boy’s difficulty to control his impulses.

Although impulsive boys are also likely to be hyperactive, adult men are less likely to continue to exhibit hyperkinetic behaviors. As discussed in the next chapter, boys who exhibited significant hyperactivity as children commonly lose some of the “driven by a motor” quality by middle adolescence, and hyperactivity as a symptom in adult men is more rare. A few adult males, however, retain the symptoms of hyperactivity long into their adult years.

Impulsivity and hyperactivity present differently in various settings and across different age groups. It is important for clinicians to review the patient’s functioning in these settings to determine whether hyperactivity and/or impulsivity are present in different aspects of life. Such review is necessary to make the diagnosis, because the DSM requires the presence of the symptoms in at least two settings to make the diagnosis (APA, 2000, p. 92).

Home. Some symptoms of impulsivity are relatively obvious and easy to recognize. For example, a young boy will run out into the street to chase a ball, forgetting to look whether a car is coming his way. Although this behavior is typical of very young children, by the time boys reach school age, they are expected to use sufficient self-control to be able to suppress the impulse to chase the ball into the street and recognize that they need to first stop and look to see if doing so is safe. Boys with ADHD find this difficult, and so they may place themselves in danger because they seemingly act without thinking.

Of course, impulsivity is evident in day-to-day behaviors that do not necessarily reflect danger. Boys with ADHD have quick reactions and often act without thinking. This is evident in many decisions they make; for example, problems suppressing the impulse to continue playing when it is time to start doing homework, or difficulties accepting that it is time to stop watching television because it is time to start getting ready for bed. Boys who are impulsive frequently have difficulties accepting tasks that are not “fun”; for example, performing house chores or following a morning routine to get ready for school. Consequently, boys with ADHD frequently argue with their parents. This results in a number of secondary reactions, discussed later in this chapter.

Boys who are hyperactive exhibit additional management difficulties. They have problems sitting still at meals. They tend to use high levels of physical activity during play and can be very noisy. They are likely to roughhouse with siblings, which often results in conflicts. All in all, parents often find these behaviors frustrating, and therefore boys with ADHD frequently get reprimanded, scolded, and punished.

When boys become teens, hyperactivity usually becomes less apparent, but impulsivity may persist. Teenagers primarily display the symptoms of impulsivity in their decision making. Impulsive adolescents are more likely to make decisions with little forethought and may exhibit poor judgment, including spontaneously breaking house rules (e.g., going out of the home to see friends at inappropriate times, such as close to bedtime), frequently changing their mind about activities and interests, agreeing to partake in an event and deciding not to do it at the last minute, performing mischievous behaviors on the spur of the moment, and so on. Of course, the presence of these symptoms does not necessarily constitute the evidence of any psychological disorder. When impulsive behaviors and decisions are performed so frequently that the teen’s day-to-day existence becomes adversely affected to a significant degree, however, problems with impulsivity may be apparent.

Like teens, adult men are less likely to exhibit symptoms of hyperactivity, but they may continue to exhibit impulsivity. Although to some degree teenagers may be impulsive because they enter a stage in their life when they test limits and experiment with the degree to which they can make their own decisions, men are presumed to have grown out of this developmental phase and usually are able to exercise more mature judgment. Thus, when notable impulsivity and poor judgment are evident in adult men, they may indicate clinical significance. Impulsive men continue to exhibit behaviors that are often regarded as immature: They have difficulties saving money and frequently neglect their financial obligations because they spontaneously decide to take trips, attend events, remodel the home, and so on, usually with little notice and preparation. In general, they frequently change interests, plans, and pursuits. The clinician must again be cautioned that a limited amount of these symptoms does not constitute psychopathology. In fact, adults who are able to maintain some spontaneity are often regarded as fun people, because they allow their life to be somewhat unpredictable. When an adult male, however, is so spontaneous and unpredictable that he seems to have difficulties living up to adult responsibilities, it is likely that clinically significant impulsivity is evident.

Although teens and men are less hyperactive, some do exhibit a high degree of hyperkinesis, which may present as restlessness during times when others in the family seem able to remain relatively still, such as during meals or when watching television. Rather than gross motor overreactivity, this restlessness can take the form of significant fidgeting with hands and feet, often accompanied by a subjective sense of restlessness or difficulties remaining seated (Murphy & Barkley, 1996a).

Out-of-Home Settings. Boys who are hyperactive/impulsive often exhibit difficulties in outside settings. When boys with ADHD accompany parents during shopping trips (e.g., in the supermarket), they are easily affected by what they see on the shelves, and they commonly place items into the shopping basket that caught their interest regardless of whether their parents allowed them to do so. When boys with ADHD see an item they want, they expect a parent to get it, and they usually tantrum when they do not get their own way. Hyperactive boys are also known to wander (or run) away from their parents in stores, requiring a chase that results in a power struggle to bring them under control.

In restaurants, boys with ADHD often present with similar problems. They find it difficult to sit still, and they impulsively wish to order items from the menu that their parents do not approve of. They tend to wander away from the table and require parents to chase after them. They are often loud during meals, and their parents often feel embarrassed.

Attendance at religious services is particularly difficult for boys with ADHD. In a church (or a similar place of worship) parishioners are usually expected to sit still, remain quiet, and follow the protocol of the services (stand during appropriate times, repeat certain phrases with the entire congregation, etc.). Boys with ADHD find it difficult to sit quietly for long periods of time, particularly during an event that does not hold their interest. Consequently, boys with ADHD typically stand out during religious ceremonies and annoy others with their loud and restless behaviors. Again, parents become embarrassed, and a conflict with the boy is likely to ensue.

As noted before, teens and adults with ADHD are less likely to exhibit significant hyperactivity, but impulsivity may continue to be evident. They may exhibit poor control over spending habits and seem unable to resist temptation when faced with an item they desire, even when they obviously cannot afford it. They may change plans on the spur of the moment, even if the planned event was previously agreed to and involved significant commitment of time and effort from others. They may agree to go to a specific place and come back at a specific time and then change their mind without notice about the destination or time to return, which may be very frustrating to parents and spouses. As previously noted, others will generally tend to describe the behaviors as immature and unpredictable.

Some teens and men may retain the motor restlessness they exhibited when younger and still have difficulties attending settings where it is necessary to remain quiet and still (such as religious events, theater performances, etc.). In addition, teens and males who present symptoms of impulsivity and hyperactivity often like activities that require high motor output, such as extreme sports. In fact, the preference for physical activities that involve some physical danger and risk taking has been reported as common among teens and males with ADHD (Drechsler, Rizzo, & Steinhausen, 2007). Risk-taking behaviors may also be exhibited in day-to-day behaviors. For example, men with ADHD are much more likely to have poor driving records and are prone to motor vehicle accidents (Barkley, 2006).

School and Work. Boys who are impulsive and hyperactive have difficulties remaining still during lectures and tend to be disruptive in the classroom. At times, they may leave their desk and interfere with other students’ efforts to pay attention in class. Young boys with ADHD, those who are in kindergarten, first grade, and second grade, are also known to call out without raising their hand. When a teacher asks a question of the class, boys with ADHD who know the answer experience a strong urge to respond, and because their impulse control is poor, they find it difficult to suppress that urge. Thus, whereas other children raise their hand to indicate that they know the answer, boys with ADHD call it out right after they hear the question. Teachers usually do not appreciate this behavior and reprimand those students.

Boys who are hyperactive/impulsive are especially known to present with difficulties in settings with less structure. During lunch, on the playground, in the gym class, or during music and art classes, boys with ADHD easily become overstimulated by the amount of activity, sound, and movement that is going on around them, further reducing their ability to exercise self-control.

Teenagers and men with ADHD may continue to be fidgety and impulsive. As a consequence, their abilities to succeed in high school and college may be significantly compromised. They may feel restless in classes and have difficulties sitting through lectures and presentations. When trying to complete assignments, they may find it hard to remain in one place long enough to do any significant amount of productive work. They may change their mind frequently about what field of study they want to pursue or what classes they want to take. They may frequently drop out of classes or fall behind because of missing assignments. Generally, boys with ADHD are much more likely to leave high school without graduating (Hinshaw, 2002) and are much less likely to complete a college education (Johnston, 2002).

Impulsive men also present safety risks within the workplace. When performing tasks that require safety precautions, they may impulsively skip a step or decide to do a portion of the routine differently, thus compromising their ability to perform the task safely. Indeed, men with ADHD are often described as accident prone, are more likely to be involved in accidents at work, and are at a higher risk for work-related injuries (Barkley, 2006).

Peer Relationships. Boys with ADHD often exhibit difficulties while interacting with their peers. Impulsive children have difficulties sharing their toys. Boys with ADHD often find it hard to suppress their impulse to possess and control the toy entirely, and they feel encroached upon when another child wants to play with that toy. They are likely to overreact and consequently are perceived by their peers as bossy and controlling.

During play activities, boys with ADHD often like to remain in charge and have difficulties accepting that rules must be arrived at by consensus. When another child suggests a rule that the boy with ADHD disagrees with, he has difficulties resisting the impulse to resist and often becomes argumentative. When the dispute is not resolved to his satisfaction, a boy with ADHD is likely to “take his ball and go home.” Peers are likely to avoid interacting with a boy who exhibits such behaviors.

Boys with ADHD also have difficulties joining an existing social activity. When seeing a group of friends talking or playing, a boy with ADHD is likely to barge i...

Table of contents

• Cover
• Halftitle
• Title Page
• Copyright Page
• Contents
• Series Editor’s Foreword
• Preface
• SECTION 1. Etiology, Epidemiology, and Course
• SECTION 2. Assessment and Diagnosis
• SECTION 3. Counseling and Psychotherapy
• SECTION 4. Educational Interventions
• SECTION 5. Medical Approaches
• References
• Index