Evidence-Based Counseling Therapies

for Attention-Deficit/Hyperactivity Disorder in Adults

Jeffrey A. Ahonen

Attention Deficit/Hyperactivity Disorder (ADHD) in Adults

• ADHD originally was considered to be a childhood disorder that disappeared with age (Lange, Reichl, Lange, Tucha, & Tucha, 2010).

• Recognition arose during the 1990s that it is a chronic, persistent disorder that remains in adulthood in many cases (Lange, Reichl, Lange, Tucha, & Tucha, 2010).

• The estimated prevalence rate for adult ADHD ranges between 1% and 6% of the adult population in the United States (Kolar et al., 2008).

• In adult ADHD patients, inattention, disorganization, and impulsivity can bring about functional difficulties at home, at college, and at the workplace (Kolar et al., 2008).

• Adults with ADHD also exhibit a higher prevalence of anxiety, depression, and antisocial behaviors than the general population (Kolar et al., 2008).

The Changing Conceptualization of Adult ADHD

• The conceptualization of a disorder has important implications for the way we diagnose and treat that disorder (Maddux & Winstead, 2012, p. 3).

• DSM–IV (APA, 1993) is the first diagnostic manual to consider a diagnosis of ADHD in an adult patient (Lange, Reichl, Lange, Tucha, & Tucha, 2010).

• Under DSM-IV, ADHD was grouped with the disruptive behavior disorders (APA, 1993). This conceptualizes ADHD as primarily a behavioral issue.

• Under DSM-5, ADHD is considered to be one of the neurodevelopmental disorders (APA, 2013). This conceptualization views ADHD as an issue having neurodevelopmental roots and perhaps requiring a multifaceted approach to treatment.

• This is particularly important in treating adults diagnosed with ADHD, as these issues may be all the more deeply rooted and consequently more complex to treat (Kolar et al., 2008).

Diagnostic Criteria of Adult ADHD under DSM-IV

In order to establish a diagnosis of ADHD, whether for child or adult, under DSM-IV, the patient’s clinical presentation must satisfy five criteria:A. At least six symptoms of inattention or hyperactivity-

impulsivity have persisted for at least six months, to a degree that is maladaptive and inconsistent with developmental level.

B. These symptoms were present prior to the age of seven.C. Impairment is manifested in at least two different settings.D. Clear evidence is presented of clinically significant

impairment in social, academic, or occupational functioning.E. The symptoms do not occur during the course of certain

other disorders and are not better accounted for by another mental disorder (APA, 2000, pp. 92-93).

Diagnostic Criteria of Adult ADHD under DSM-IV

It is in the discussion of the typical course of the disorder that DSM-IV highlights, albeit briefly, the diagnosis of ADHD in adults:

In most individuals, symptoms (particularly motor hyperactivity) attenuate during late adolescence and adulthood, although a minority experience the full complement of symptoms of Attention-Deficit/Hyperactivity Disorder into mid-adulthood. Other adults may retain only some of the symptoms, in which the diagnosis of Attention-Deficit/Hyperactivity Disorder, In Partial Remission, should be used. The latter diagnosis applies to individuals who no longer have the full disorder but still retain some symptoms that cause functional impairment. (APA, 2000, p. 90)

Diagnostic Criteria of Adult ADHD under DSM-5

In order to establish a diagnosis of ADHD, whether for child or adult, under DSM-5, the patient’s clinical presentation must satisfy five criteria:A. At least five symptoms of inattention or hyperactivity-

impulsivity have persisted for at least six months, to a degree that is inconsistent with developmental level and that negatively impact directly on social and academic/occupational activities.

B. These symptoms were present prior to the age of twelve.C. Impairment is manifested in at least two different settings.D. Clear evidence is presented of clinically significant

impairment in social, academic, or occupational functioning.E. The symptoms do not occur during the course of certain

other disorders and are not better accounted for by another mental disorder (APA, 2013, pp. 59-60).

Diagnostic Criteria of Adult ADHD under DSM-5

Although the broad view of the disorder may have shifted with the implementation of DSM-5, the specific diagnostic criteria for adult ADHD remain basically the same as that in DSM-IV, with two notable exceptions:1. The age of onset of symptoms is raised from seven years

old under DSM-IV (APA, 1993) to twelve years old under DSM-5 (APA, 2013). This shift “conveys the importance of a substantial clinical presentation during childhood” while also acknowledging the “difficulties in establishing precise childhood onset retrospectively” (APA, 2013, p. 61).

2. The threshold number of symptoms necessary to establish a diagnosis of ADHD in an adult (age 17 or older) is lowered from six in DSM-IV (APA, 1993) to five in DSM-5 (APA, 2013). This acknowledges both the fact that the behaviors attendant with ADHD tend to diminish as development proceeds from adolescence into adulthood (Kolar et al., 2008), yet can still pose clinically significant impairment in the adult due to the complex and different demands imposed by these symptoms upon the adult (Kolar et al., 2008).

Coding Specifiers of Adult ADHD under DSM-5

Under DSM-5, ADHD is coded under one of three subtypes:• 314.00 (F90.0) Attention-Deficit/Hyperactivity Disorder,

Predominantly inattentive presentation.• 314.01 (F90.1) Attention-Deficit/Hyperactivity Disorder,

Predominantly Hyperactive/impulsive presentation.• 314.01 (F90.2) Attention-Deficit/Hyperactivity Disorder,

Combined presentation. (APA, 2013, p. 60).DSM-5 also codes severity according to three categories:1. Mild – few symptoms and minor impairment in functioning;2. Moderate - symptoms and impairments fall between “mild”

and “severe;”3. Severe – many or particularly severe symptoms, or marked

impairments in functioning (APA, 2013, pp. 60-61).

Additional Categories of Adult ADHD under DSM-5

The DSM-5 includes two additional categories of ADHD. Both of these categories share a clinical presentation of symptoms characteristic of ADHD and clinically significant distress or impairment in functioning within social, occupational, or other important areas, yet the diagnostic criteria for ADHD or another neurodevelopmental disorder are not fully satisfied (APA, 2013, pp. 65-66) .• “Other Specified Attention-Deficit/Hyperactivity Disorder

(314.01; F90.8) is used when the clinician “chooses to communicate the specific reason that the presentation does not meet the criteria (APA, 2013, pp. 65-66).

• “Unspecified Attention-Deficit/Hyperactivity Disorder” (314.01; F90.9) is used when the clinician chooses not to communicate that reason, and may include the case in which there is insufficient information to make a more specific diagnosis (APA, 2013, p. 66).

Evidence-Based Counseling Therapies for Adult ADHD

• “Although there is no cure for ADHD, there are well-established and evidence-based options for the treatment of adults with the disorder” (Daly, Nicholls, & Brown, 2016, p. 45).

• Many experts consider pharmacotherapy, particularly with stimulants, to be the primary treatment option for adults (Daly, Nicholls, & Brown, 2016, p. 45).

• However, nearly half of all adult patients with ADHD are not able to tolerate these medications, do not respond to them, or fail to reach optimal outcomes on medication alone (Dittner, Rimes, Russell, & Chalder, 2014).

Evidence-Based Counseling Therapies for Adult ADHD

• As applied in the treatment of ADHD, cognitive behavioral therapy provides structure as well as coping and problem-solving skills (Daly, Nicholls, & Brown, 2016, p. 52).

• The specific strategies associated with cognitive behavioral therapy include assisting the client to identify and modify negative cognitions associated with the task avoidance, lack of motivation, and negative affect. The therapist then assists the client in challenging these negative cognitions, with the goal of diminishing hopelessness and increasing motivation (Daly, Nicholls, & Brown, 2016, p. 52).

• In a review study of psychotherapeutic treatments for adult ADHD by Vidal-Estrada and colleagues (2012), cognitive behavioral therapy was “the most effective treatment modality for reducing symptoms of ADHD as well as comorbid symptoms of anxiety and depression” (Daly, Nicholls, & Brown, 2016, p. 52).

Cognitive Behavioral Therapy

Evidence-Based Counseling Therapies for Adult ADHD

• Meta-cognitive therapy, which uses cognitive behavior principles, can provide a framework for organizational interventions in adult ADHD cases (Daly, Nicholls, & Brown, 2016, p. 53).

• In this therapeutic system, counselors help clients to challenge and subsequently eliminate maladaptive cognitions, replacing them with adaptive cognitions that lead to better organization and on-time task completion. The therapist and client collaborate on establishing a system of rewards for timely completion of tasks, which reinforces the desired behavior and shapes a positive the cognitive-behavioral pathway (Daly, Nicholls, & Brown, 2016, p. 53).

• Studies of the effectiveness of meta-cognitive therapy with adult ADHD clients have demonstrated significant improvement in attention and organizational skills (Wiggins et al., 1999) as well as decreases in severity of ADHD symptoms (Solanto et al., 2010), suggesting that this a promising avenue of treatment for adult ADHD patients (Daly, Nicholls, & Brown, 2016, p. 53).

Meta-Cognitive Therapy

Evidence-Based Counseling Therapies for Adult ADHD

• Support therapy and family therapy are treatment modalities for adult sufferers of ADHD that are effective not only in treating low-esteem, poor anger control, and the like, but in redeveloping relationships within peer networks and family members (Daly, Nicholls, & Brown, 2016, p. 53).

• These system-oriented approaches aim to resolve the client’s inaccurate judgments about himself as well as the inaccurate judgments of others about the client’s symptoms and underlying disorder (Daly, Nicholls, & Brown, 2016, p. 52).

• These therapies consequently present a hopeful, multifaceted approach to the complex of personal and interpersonal problems encountered by the adult ADHD patient and his social network. (Daly, Nicholls, & Brown, 2016, p. 54).

Supportive TherapyandFamilyTherapy

Conclusions• The problems presented by an adult sufferer of attention-

deficit/hyperactivity disorder are complex and challenging. • The conceptualizations of adult ADHD in DSM-IV-TR and DSM-

5 provide research-based guidance in approaching the diagnosis and treatment of this disorder.

• While it is a complex neurodevelopmental disorder that is all the more challenging to treat in the adult, several evidence-based treatment modalities provide hope for the client and encouragement for the therapist in overcoming the symptoms of this chronic and pervasive disorder, so that the adult having ADHD can cope and thrive.

ReferencesAmerican Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: American Psychiatric Association.American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.Daly, B. P., Nicholls, E., & Brown, R. T. (2016). Attention-deficit/hyperactivity disorder in adults. Boston, MA: Hogrefe Publishing.Dittner, A. J., Rimes, K. A., Russell, A. J., & Chalder, T. (2014). Protocol for a proof of concept randomized controlled trial of cognitive-behavioural therapy for adult ADHD as a supplement to treatment as usual, compared with treatment as usual alone. BMC Psychiatry, 14:248. doi:10.1186/s12888-014-0248-1.

ReferencesKolar, D., Keller, A., Golfinopoulos, M., Cumyn, L., Syer, C., & Hechtman, L. (2008). Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatric Disease and Treatment, 4(2), 389–403.Lange, K. W., Reichl, S., Lange, K. M., Tucha, L., & Tucha, O. (2010). The history of attention deficit hyperactivity disorder. Attention Deficit Hyperactivity Disorder, 2, 241–255. doi:10.1007/s12402-010-0045-8Maddux, J. E., & Winstead, B. A. (2012). Psychopathology: Foundations for a contemporary understanding (3rd ed.). New York, NY: Routledge.Paris, J., Bhat, V., & Thombs, B. (2015). Is adult attention-deficit hyperactivity disorder being overdiagnosed? Canadian Journal of Psychiatry, 60(7), 324–328.