A Comprehensive Guide To Attention Deficit Disorder In Adults

Research, Diagnosis and Treatment

Kathleen G. Nadeau

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134862894
• Edition: 1
• Topic: Education
• Subtopic: Inclusive Education

This groundbreaking volume, written by pioneering clinicians and researchers firmly convinced of the neurobiological underpinnings of ADD in adults, is the first to provide broad coverage of this burgeoning field. Written for professionals who diagnose and treat adults with ADD, it provides information from psychologists and physicians on the most current research and treatment issues regarding our understanding of ADD as a neurobiological disorder. According to the contributors, ADD in adults may be responsible for difficulties ranging from minor attention, memory, and organization problems in well-functioning adults to drug abuse and criminal behavior.

A Comprehensive Guide to Attention Deficit Disorder in Adults begins by addressing the history of ADD and the evolution of our understanding of the disorder. The neurobiology of ADD is examined, laying a solid foundation for the clinician to develop a scientific understanding of this complex syndrome. The assessment and differential diagnosis of ADD is explored from the perspectives of a variety of specialists in the field. This includes an exploration of the interrelationships between attention deficit disorder and other neurodevelopmental disabilities that may interact with ADD to affect cognitive functioning, and an examination of the connections between ADD and a host of psychiatric conditions. Also covered is the process of differential diagnosis from a neurological perspective, which will help the non-medically trained clinician better to determine when a complete neurological evaluation seems warranted in the assessment process. Authors examine ADD with and without hyperactivity and describe a wide range of assessment tools that can be useful in developing a full diagnostic picture of different conditions that must be addressed in treating adults with the disorder. A wealth of experience, highly practical suggestions, and an optimistic outlook are the hallmark of the section on treatment. The authors strongly recommend a multifaceted treatment plan combining medication, psychotherapy, and addressing the pervasive self-esteem issues which typically haunt the adult whose condition has gone untreated. Specific treatment issues for Adults with ADD are also discussed. These include: -
* the development of practical life management skills
* the difficulties in relationships
* ADD within the context of marriage and family
* and higher education and the workplace. The volume concludes with a discussion of the legal implications of the diagnosis of ADD in adults as it pertains to education and employment, the important role of support groups for adults with ADD, and a thought-provoking examination of current and future research including the need for increased public recognition of ADD in adults. A Comprehensive Guide to Attention Deficit Disorder in Adults is a pioneering volume that will bring the most current information available to the attention of those able to help adult ADD sufferers...vocation and rehabilitation counselors, and numerous psychotherapists who recognize symptoms of depression and anxiety, but perhaps overlook the underlying attention deficit disorder. It will stimulate the interdisciplinary research that is the key to increasing knowledge and educate those who can truly make a difference.

SECTION IV

Specific Treatment Issues for Adults with ADD

Because attention deficit disorder is manifested in all areas of life, and because each of these areas introduces specific concerns, we have attempted to address a number of major life issues for adults with ADD in this section. The chapter on life management skills discusses practical approaches to the problems posed by the cognitive difficulties associated with ADD, including problems with planning, organization, memory, distractibility, and stress management. John Ratey, Edward Hallowell, and Andrea Miller address the neurobiology of relationships, interweaving our understanding of the neurobiology of ADD with widely recognized difficulties in relationships experienced by many adults with ADD. Ellen Dixon expands our understanding of how ADD affects relationships by discussing ADD within the context of marriage and the family. Also included is an important chapter on the special issues pertaining to women with ADD, which discusses the disorder within the context of the social conditioning of women, as well as considering the additional impact of hormonal variations experienced by women.

The last two chapters in this section target ADD issues within two of the most challenging areas for adults with ADD: higher education and the workplace. Although universities have recognized the need for special supports and accommodations for students with learning disabilities, the recognition that students with ADD have similar needs is quite recent. Mary Richard, President-elect of CH.A.D.D., head of the Adult Issues Committee of CH.A.D.D., and a staff member of the office of Services for Persons with Disabilities at the University of Iowa, provides a comprehensive discussion of the needs of postsecondary students with ADD. My chapter on ADD in the workplace completes the section on special topics. Although problems in the workplace are probably one of the most common presenting complaints when an adult seeks assessment for ADD, there had been remarkably little writing and less research on the topic. My chapter here is an attempt to compile and organize my clinical experience on the impact of ADD in the workplace, and, I hope, may provide the starting point for much needed empirical investigation. With the passage of the Americans with Disabilities Act, discussed in detail in section V, the need for accurate documentation about appropriate accommodations in the workplace for adults with ADD is ever more acute.

11

Life Management Skills for the Adult with ADD

KATHLEEN G. NADEAU

The clinician who works successfully with adults who have attention deficit disorder (ADD) needs to view the disorder from a broad perspective, taking into consideration all of the aspects of daily functioning that are affected by the cognitive skills deficits associated with ADD. Zametkin's research (Zametkin et al., 1990) has implicated the frontal lobes as one of the major neurological structures involved in attention deficit. As has been widely documented, the frontal lobes are considered to be the area of the brain that controls “executive functions” (Luria, 1966; Stuss & Benson, 1986). Executive functions are the oversight or managerial functions so often af- fected in adults with ADD. Luria (1973a) wrote that one of the primary functions of the frontal lobes was the verbal regulation of motor behavior (i.e., thinking and talking about what we do before we do it). The executive functions of the brain include attention, memory, organization, planning, initiation, self-inhibition (self-discipline), ability to change set, strategic behavior, and self-monitoring in relation to time (time management). It is this broad set of concerns–executive functions–that I address in this chapter, considering their effect on practical life management skills.

Just as the assessment of attention deficits (discussed in section II, this volume) requires consideration of problems from a neurological, neuropsychological, educational, psychiatric, and psychological perspective, treatment also requires a multi-disciplinary approach. Other chapters in this volume describe the roles of the psychopharmcologist, the neurologist, the neuropsychologist, the career consultant, and the psychotherapist in treating adults with ADD. In this chapter, the emphasis is on certain aspects of the psychotherapist's role that are more analogous to that of the rehabilitation counselor, that is, focusing on practical ways to enhance daily functioning for the ADD adult.

Executive function disorders (as discussed in chapter 4, this volume) can result from a host of neurological conditions other than ADD. Much of our knowledge about improving executive functioning and developing compensatory strategies is derived from work with individuals whose executive function problems resulted from these other neurological conditions, including head injury. One such treatment model has been adapted for use with adults with ADD (Goodwin & Bolton, 1991). The model suggests a three-pronged approach which emphasizes (1) retraining cognitive functions, (2) developing internal and external compensatory strategies, and (3) restructuring the physical and social environment to maximize functioning. Goodwin and Corgiat (1992) report using this model successfully in their work with a college student with ADD.

In addition to the rehabilitation model, some of the techniques suggested in this chapter are based on my own clinical experience, as well as the reported clinical experience of Hallowell (see chapter 9, this volume), Gabrielle Weiss (Weiss & Hechtman, 1993), Lynn Weiss (1992), and the personal and clinical experience of Kelly and Ramundo (1993). As Weiss and Hechtman write in their newly revised book, “Controlled treatment studies involving medication, psychological therapies and their combination are sorely lacking and urgently needed” (1993, p. 406). The efficacy of these approaches is supported only anecdotally, at this point, and has yet to pass the test of clinical trials.

ROLES OF THE THERAPIST

Numerous adults with ADD have reported to me that psychotherapy of a more traditional insight-oriented type has proved largely ineffective in helping them with their ADD symptoms. In fact, some of them have felt that their previous psychotherapy was demoralizing and destructive due to the therapist's psychological interpretations of neurological symptoms such as forgetfulness or lack of follow-through. Many struggled for years with self-blame and guilt, attempting to understand the psychological basis for their “immature,” “passive-aggressive,” or “self-defeating” patterns. When receiving psychotherapy that focused on their ADD, these same individuals were able to develop a more hopeful and effective approach to life, after moving through phases of relief (as they relinquished their self-blame) and sadness (as they faced the fact of their lifelong neurobiological disorder).

Therapist as Educator

An essential role for the therapist of a client with ADD is to educate and thereby enable the client to better understand the neurological basis for the ADD symptoms. The process of education can be supported through reading, participation in support groups for adults with ADD, and the ongoing process of therapy. Providing concrete examples from the lives of other adults with ADD and showing how certain patterns relate to the neurobiology of ADD can be helpful. Many clients find that instructive anecdotes about others can help them see their own behavior in a more objective light.

Therapist as Supporter

A critical goal of the therapist should be encouraging the adult with ADD to move from victimization to empowerment in relation to the ADD symptoms. The individual needs to firmly embrace the concept that ADD presents challenges which must be actively managed through a range of strategies. A crucial task for the therapist is to inculcate this attitude and discourage the common hope that medication will eliminate problems without further effort. An ADD diagnosis should not become an excuse for underfunctioning, but rather be a challenging fact of life that requires ongoing active strategic management. As Barbara Fisher so succinctly put it during her Adult ADD Workshop at the first annual conference on adult ADD in Ann Arbor, Michigan, in May 1993, “You need to learn to manage your ADD so that it won't manage you.”

Therapist as Interpreter

Because distractibility, absentmindedness, disorganization, and reactivity to stress pose problems for everyone to some extent, adults with ADD may often encounter skepticism as they attempt to explain the disability to coworkers, supervisors, spouses, or others. The clinician can play a therapeutic role by supporting the client in seeing this disability as “valid” and by interpreting the client's ADD patterns to the significant people in the client's life, helping them to accept the validity of the disabling effect of attention deficits. Spouses and employers who recognize the validity of practical problems that result from ADD should not be expected to simply overlook disorganization, forgetfulness, or chronic lateness, but rather, to interpret these behaviors correctly, as the result of ADD, not indifference or low motivation.

The interpretation of ADD symptoms to family members, coworkers, and employers is the first step toward developing accommodations in the home and work environment that can reduce the impact of the symptoms (see chapter 16, this volume, for a more complete discussion of disclosure of ADD in the workplace). Adults with ADD legitimately require certain accommodations and deserve support and understanding as they work to restructure their environment and learn strategies to compensate for dysfunctional patterns.

Therapist as Structurer

In my experience as well as that of others (see Hallowell, chapter 9, and Murphy, chapter 8, this volume), the clinician who wishes to become most effective with ADD adults needs to modify the passive-receptive-interpretive therapeutic role to become more active and directive. Because ADD individuals typically have difficulty with planning, organization, and prioritization, it may be helpful for the therapist in this particular role to begin with the structure of the psychotherapy session itself. Initially, the therapist can play a useful role by providing guidelines within each therapy session, and by helping the client to maintain focus. Later, the therapist can assist the client in developing self-structuring skills. It is often useful for the client to maintain a journal of events between sessions, keeping a log of “homework” completed during the week and jotting down thoughts or observations to discuss in the next therapy session. Without this degree of structure, the client with ADD may tend to skip from topic to topic in the therapy session, just as in daily life, never really staying focused long enough to develop awareness and strategies.

Therapist as Rehabilitation Counselor

Currently, there is no single profession that provides adequate training in the treatment and accommodation of cognitive impairments (Sohlberg & Mateer, 1989). Various aspects of relevant training exist within the fields of neuropsychology, cognitive psychology, educational psychology, and rehabilitative training. There is much work to be done to develop training programs for therapists in cognitive training and environmental restructuring for the ADD adult. Many of the approaches and strategies that seem useful for work with adults with ADD are derived from those of the rehabilitation counselor who focuses very concretely on practical ways to improve aspects of daily functioning. In his role as “rehabilitation counselor” the therapist can suggest many concrete modifications to the client's daily routine and to his or her home, school, and work environments.

ASSESSMENT OF EXECUTIVE FUNCTIONING

Standard psychological and neuropsychological testing is not sensitive, for the most part, to frontal lobe dysfunction (Sohlberg & Mateer, 1989). Stuss and Benson (1986) write that perhaps the greatest confusion regarding the function of the frontal lobes lies in the relationship between the frontal lobes and cognition. Many case studies show that individuals with normal-range cognitive functioning, as measured by the Wechsler Adult Intelligence Scale-Revised, manifest severe deficits in functional ability. Several researchers (Luria, 1973b; Stuss & Benson, 1986) suggest that the frontal lobes do not involve primary cognitive functions, but rather are responsible for coordinating and actualizing cognitive processing through attention, motivation, regulation, and self-monitoring. Lezak (1976) sheds some light on the puzzle of adults with ADD who often test in the average or above-average range on cognitive tests while still manifesting many functional deficits. Lezak writes that cognition refers to how much a person knows and what the person can do, whereas executive functions relate to how or whether the individual performs certain tasks.

Assessment of Executive Functions

There are several standardized tests commonly used to measure executive functioning. They include the Halstead Category Test (Halstead, 1947), the Wisconsin Card Sorting Test (WCST), and the Porteus Maze Test (Porteus, 1950). All three tests investigate planning ability. Other experimental tests have been developed to assess frontal lobe functioning. Shallice (1982) developed the Tower of London Puzzle, which requires sequencing and planning. Lezak (1983) believed that standard tests of executive function were not sensitive to issues of initiation and goal-directed behavior. She developed her unstructured Tinker Toy Test to assess initiation, goal-directed behavior, and planning ability (Lezak, 1982). These tests can be used only impressionistically, however, since norms and standardization are lacking. Sohlberg and Mateer (1989) also describe informal measures of executive functioning through providing the patient with a multistep task, and then observing the patient's performance.

Therapist Assessment o...