Clinician's Guide to Adult ADHD. Assessment and Intervention

303 Pages·2002·4.62 MB·English

by  Sam Goldstein and Anne Teeter Ellison (Auth.)

srotubirtnoC
Numbers in parentheses indicate the pages on which the authors' contributions begin.
Russell Barkley (43), Department of Psychiatry, Patricia Latham (205), National Center for Law
University of Massachusetts Medical Center, Wor- and Learning Disabilities, Cabin John, MD 20818
cester, MA 01655
Peter Latham (205), National Center for Law and
Robert Brooks (127), Harvard Medical School, Learning Disabilities, Cabin John, MD 20818
McLean Hospital, Belmont, MA 02478
Kevin Murphy (85), Department of Psychiatry,
C. Keith Conners (71), Department of Psychiatry University of Massachusetts Medical Center, Wor-
and Behavior Sciences, Duke University Medical cester, MA 01655
Center, Durham, NC 27705
Kathleen Nadeau (107), Chesapeake Psychological
Rob Crawford (187), Life Development Institute, Services, Silver Spring, MD 20910
Glendale, AZ 85308
Thomas W. Phelan (241), Glen Ellyn, IL 60137
Veronica Crawford (187), PART, Glendale, AZ
85308 Jeffrey Prince (165), Massachusetts General Hos-
pital, Boston, MA 02114
Anne Teeter Ellison (1), Department of Educa-
tional Psychology, University of Wisconsin-Mil- Nancy Ratey (261), National Attention Deficit Dis-
waukee, Milwaukee, WI 53221 order Association, Wellesley, MA 02482
Sam Goldstein (25), Neurology, Learning and Be- Arthur Robin (279), Children's Hospital of Mich-
havior Center, University of Utah, Salt Lake City, igan, Detroit, MI 48201
UT 84102
John Watson (xxi) 1759 E. Ski View Dr. Sandy, UT
Michael Gordon (43), Department of Psychiatry, 84092
State University of New York, Upstate Medical
School, Syracuse, NY 13210 Tim Wilens (165), Massachusetts General Hospital,
Boston, MA 02114
Diane Johnson (71), Department of Psychiatry and
Behavioral Sciences, Duke University Medical Susan Young (147), Department of Psychology,
Center, Durham, NC 27710 Institute of Psychiatry, De Crespigny Park,
London, UK, SE5 8AF
Patrick J. Kilcarr (219), Georgetown University's
Center for Personal Development, Washington,
D.C. 20057
XV
droweroF
Controversy has always accompanied the concept (if one is to believe one recent FDA maven's assess-
and diagnosis of Attention Deficit/Hyperactivity ment). The anti-Ritalin caucus among strident self-
Disorder (ADHD), both in lay and professional appointed "Centers for the Public Interest" and
circles. Perhaps resistance to the concept lies in those worried about children "running on Ritalin,"
the fact that in some sense the disorder echoes the now turn their venom on this new-fangled invention
19th century concept of a "failure of will," (Wil- of ADULT ADHD as further evidence of moral
liam James, 1890) or "moral defect," (George Still, decline, or of an invented disorder catering to self-
1902). James had postulated that inattention was diagnosis among those seeking a competitive edge
the root cause of impulsive choices, and Still first by performance-enhancing drugs.
described a syndrome of normal IQ children who Now it is surely true that there has been a shame-
suffered from a "moral defect." Their unruly be- ful neglect of clinical and biological research on
havior, poor school work, and impulsive acts were adults with the syndrome of ADHD, with the ex-
thought to be the result of a defect in the ability to ception of a few pioneers such as Paul Wender
make correct (moral) choices. It was common at (1979) who very early saw the outlines of a distinct-
that time to conceptualize psychiatric disorders as ive disorder mirroring that of childhood "MBD".
the result of excess stimuli overwhelming the sen- But much has happened in science since those early
sorium; of distraction leading to impulsive (and years when the "brain" part of the syndrome was
hence immoral) behavior. mere speculation in the absence of hard data. There
The continuing controversy and resistance to a is now strong evidence for the worldwide preva-
medical diagnosis might lie, then, in the persisting lence of ADHD in virtually all countries studied.
belief that the cure for a weak will is moral educa- Now there is overwhelming evidence for the strong
tion, not medicine. If the controversial nature of genetic heritability of ADHD; for anatomic anom-
organicity, minimal brain damage, minimal brain alies repeatedly detected by brilliant neuroimaging
dysfunction, and attention deficit/hyperactivity ap- technologies, including PET, MRI, and fMRI.
plies to children, how much more so must be the Alan Zametkin and colleagues (Zametkin, Nordahl
allegation that it also applies to adults! Here the and Gross, 1990) opened the doors to this new field
field is rife with arguments against the diagnosis: with his demonstration in carefully assessed adult
hyperactivity disappears in adolescence, onset in probands of ADHD children, finding clear local-
childhood cannot be proven, pharmacotherapy is ized differences from normal controls on PET
less effective in the adults, disorders of depression, scans. Converging evidence suggests that for
anxiety, sociopathy, borderline personality, and many ADHD patients there are dopaminergic
many other psychiatric illnesses account for the defects in receptor or re-uptake mechanisms, par-
putative attentional problems, and so on and on. ticularly in the frontal lobes. Neuropsychological
Conspiracy theorists harken to some of their fa- investigations also confirm the presence of persist-
vorite explanations for the sudden burst of interest ing defects in executive functions, particularly for
in adult ADHD, such as a collusion among aca- working memory, disturbances of time perception,
demics, psychiatrists, and drug companies trying to and "forgetting to remember" (meta-memory).
restore income lost with the advent of managed care Symptomatic studies also detect, as it had previ-
XVI I
xviii Foreword
ously discovered in adolescents, the emergence of a The current volume takes a comprehensive fresh
distinctive failure-related syndrome of low self- look at both the clinical and data-related issues
esteem, obviously associated with a lifelong history surrounding adult ADHD. A wealth of clinical
of interpersonal, academic and social failure. observation and new empirical data are presented
As often happens in emerging sciences, prac- here, and will hopefully inform the clinician, re-
ticing clinicians may advance beyond the known searcher, and patient alike, prompting them to
certainties provided by empirical research and clin- put aside controversy in favor of facts, thereby
ical trials. Such data are now pouring in, and new insuring that adult ADHD receives the respect
compendia of research and practice, such as the and attention it richly deserves as a disabling con-
recent excellent text by another pioneer, Gabrielle dition requiring compassion, informed care, and
Weiss and colleagues (1999), are springing up to diligent research, rather than the benign neglect of
guide both new research and practice. the past.
C. Keith Conners, Ph.D.
Professor Emeritus of Psychiatry and Behavioral Sciences
Duke University Medical Center, Durham, NC
REFERENCES
,semaJ .W .)0981( ehT principles of psychology. weN York, :YN ,redneW P.H. .)9791( ehT concept of adult minimal brain -syd
.tloH .noitcnuf In .L kalleB (Ed.). Psychiatric aspects of minimal
,llitS G.F. .)2091( ehT Coulstonian serutcel no some abnormal brain dysfunction in adults. weN York, :YN Grune dna
lacisyhp snoitidnoc ni .nerdlihc Lancet, ,1 .2101-8001 .nottartS
,ssieW ,.M Hechtman, L.T., & Weiss, .G .)9991( ADHD in ,niktemaZ A.J., Nordahl, T.E., & Gross, .M .)0991( larbereC
Adulthood: A guide to current theory, diagnosis and treatment. esoculg metabolism adults with ytivitcarepyh ni doohdlihc
,eromitlaB :DM ehT Johns Hopkins ytisrevinU .sserP .tesno Archives of General Psychiatry, ,05 .043-333
ecaferP
In the fall of 2000, the wife of one of our adult ities and demands placed upon adults in compari-
patients wrote the following: son to children are certainly different, the
consequences of these problems--impaired daily
Total frustration! That's what I feel like several times
functioning--are not. What is it about the condi-
a day--or more--I hear, "I can't find my... Have you
tion we today call ADHD that has blinded clin-
seen... ? Where is my... ? If you see my..." He never
picks up after himself (dirty dishes, dirty clothes, shaving icians until just recently to recognizing that these
cream, towels, etc.). I am tired of being the maid. If he are problems of life rather than of only childhood?
uses the remote on the TV or the cordless phone, I have Perhaps their spouses are not as vocal as their
to go find them because he left them somewhere else. I
mothers, or years of impairment lead those adults
more or less raised our two big girls by myself and now I
with ADHD to suffer in silence, develop dysfunc-
am more or less raising our little boy by myself. He can't
sit still unless golf or football are on TV then he can sit tional coping strategies, or form mindsets to deny
still. So that is all he does at home is watch TV. Please do the condition or its impact. The self-regulatory
something for this man because after 20 years of mar- problems underlying ADHD are not outgrown.
riage he is making me crazy!
Though symptoms may wax and wane as individ-
This man's self-report matched his wife's observa- uals grow, it is a reasonable conclusion that the
tions. He was well aware of his problems but had majority of inattentive, impulsive, and hyperactive
long given up hope that there was much he could children grow into adults manifesting many of
do about them. The majority of his energy was these very same symptoms.
focused at work, where he had been placed on For the general public and perhaps a significant
probation a number of times. In self-report meas- percentage of medical and mental health profes-
ures he described his difficulty focusing on import- sionals, it was likely reassuring to believe that the
ant tasks and listening when spoken to, his problems caused by ADHD represented a poor fit
problems with organization, his being forgetful, between some children and their environments. It
restless, and, in the last five years, somewhat de- was likely comforting for parents to hear profes-
pressed. sionals tell them that not only was this a problem
The words of this couple are echoed again and that would be outgrown but that by simply
again by the individuals coming to our clinics. parenting their children differently they could
Although over the past 50 years the diagnostic change the condition. Certainly for some, this
category Attention Deficit Hyperactivity Disorder lead to strong, unwarranted feelings of guilt and
(ADHD) has been considered primarily a child- to the belief that they were inadequate parents and
hood condition, the experiences of clinical practice that their failings had led to this condition. Belief is
teach that a significant number of children with a powerful ally in the absence of fact. However,
ADHD appear to carry their impairing symptoms over the past ten years the belief that ADHD is just
with them into adult life. The significant and per- a childhood condition has been increasingly tested.
vasive impairments reported day in and day out for Though for some parts of the lay community and
children with ADHD has been increasingly demon- for professionals with "an axe to grind," ADHD is
strated for a significant portion of this population still reported as a condition created by inadequate
during their adult years. Though the responsibil- parenting or, even worse, as an illusion created by
xix
XX Preface
the marketing arms of drug companies and psychi- in 1902. In describing Still's disease, he suggested
atric organizations, the belief that ADHD does not that some children have difficulty with moral con-
exist or in fact does not cause impairment through- trol because they are unable to internalize rules and
out the lifetime has been tested and the results are limits and exhibit restless, inattentive, and overar-
clear. A significant number of individuals suffering oused behavior. Still did not discuss the hypothe-
with this condition in their childhood continue to sized outcome of these children into their adult
suffer and lead lives less than their capabilities. years. He was, however, quite pessimistic, believing
Perhaps another phenomena that has delayed that these children could not successfully transition
the recognition of ADHD as a lifetime condition into adulthood.
has been the history of associating these behaviors Finally, although in the late 1800s and early
only with children. This is not to suggest that adults 1900s symptoms now considered diagnostic of
don't act impulsively or experience difficulty sus- ADHD were recognized as being multicausal, in-
taining attention. They most certainly do. But for cluding the result of brain injury, the world out-
adults these symptoms historically have been con- break of encephalitis in 1917 and 1918 led to very
sidered to fall clinically within the domains of other different outcomes for affected children and adults.
conditions, including the DSM-IV Axis II diagno- Many children who recovered from the encephal-
sis of Impulsive Personality Disorder. As far as we itis presented a pattern of restless, inattentive, im-
are aware, no one has yet to test the theory as to pulsive, and hyperactive behavior. The adults who
what percentage of adults with this condition dem- recovered, however, did not so present. In extreme
onstrate histories of ADHD. Certainly, as many cases these adults became extremely catatonic and
researchers report including those contributing to unresponsive to their environments.
this text, individuals with ADHD are at signifi- Though the presence, cause, and evaluation of
cantly greater risk to develop antisocial, border- ADHD has been controversial, the issue of treat-
line, dependent, and passive aggressive personality ment for the condition has created by far the
styles. greatest controversy. Psychosocial treatments
The earliest report of symptoms traditionally such as cognitive training, once considered promis-
related to ADHD is credited to St. John the Bap- ing in directly reducing the symptoms of ADHD,
tist. Luke 1:41 cites John describing fetal hyper- are recognized as at best offering valuable interven-
activity: "The babe leapt in her womb." There are tions for adjunctive problems related to ADHD.
also allusions in many early civilizations to this Particularly in adults, problems involving self-
symptom as a problem of childhood. The Greek esteem, motivation, and the development of an
physician Galen was reported to prescribe opium atypical or dysfunctional mindset can be addressed
for restless infants (Goodman & Gilman, 1975). and resolved in counseling.
Hans Hoffman's description in 1845 of "Fidgety The greatest volume of literature in the treat-
Phil" set the tone that wriggles, giggles, rocking, ment of ADHD has been devoted to the investi-
and swinging were problems of childhood (Papa- gation of the direct benefits of psychostimulants
zian, 1995). Interestingly this poem also set the tone and related medications the symptoms of ADHD.
for these problems stemming from naughtiness. A very large, diverse, and scientifically rigorous
Naughty children are restricted from Nintendo. literature has consistently demonstrated the bene-
Naughty adults, however, are fired or sent to jail. fits of psychostimulants for ADHD across the life
Historically our society has had little empathy for span (for review, see Greenhill & Osman, 2000).
"naughty adults." Nonetheless, although stimulants offer excellent
The notion of ADHD as a childhood condition short-term symptomatic relief for the problems of
was also reinforced by the work of George F. Still ADHD, they have not been demonstrated in the
ecaferP xxi
long run to significantly alter the life course for factors related to this condition affecting adult out-
those with ADHD. Thus, from the available, well- come during the childhood years, is still very small
controlled research of children with ADHD taking in comparison to the body of research in this area.
medicine in comparison to those who do not, do Nonetheless, we believe there is a consensus among
not seem to fare significantly better into their adult practitioners that the core symptoms of ADHD
lives. Outcome as described by multiple researchers affect a significant minority of our population.
appears to be related to the adverse impact of the For affected individuals, this condition represents
consequences of living with ADHD. The environ- a poor fit between society's expectations and these
mental, educational, social, and familial factors individual's abilities to meet these expectations.
that place all growing children at risk appear to This condition is distinct from other disorders of
be catalytically driven by the symptoms of ADHD, childhood and adulthood and can be reliably
placing those with the condition at even greater evaluated and effectively treated. Finally, this con-
risk. The biopsychosocial nature of ADHD makes dition leads to a high financial cost for society for
it reasonable to conclude that it is the environment adults unable to transition into functional life. As
more than the direct treatments for ADHD that Russell Barkley noted in 1991, treatment for
predict life outcome and course for affected indi- ADHD must and will continue to be multidisci-
viduals. plinary and multimodal and, in light of continuing
We embrace the view of the symptoms of ADHD cultural trends and societal expectations, must be
as catalytic. Place an affected individual in a good maintained throughout the affected individual's
context, and ADHD may not represent a signifi- life span. Though symptoms and consequences
cant risk factor. But these symptoms certainly do may wax and wane, there is no cure leading to
not represent an asset as far as we believe and can complete recovery.
demonstrate. Place them in a child living in a dys- The first author met John when he was nearly
functional family, exposed to a poor school envir- eighteen years of age in 1987. John was the second
onment or other significant life stress, and ADHD of his parents' five children. At the time his siblings
likely represents a significant risk factor. ranged in age between six and twenty-one years.
In 1988, Carey noted that it was of little import- John's younger brother, David, had recently been
ance if one's theoretical orientation toward ADHD diagnosed with Attention Deficit Hyperactivity
saw it as a neurobehavioral phenomenon, lack of Disorder. Other siblings had not experienced simi-
fit between individual and environment or even a lar problems. John's history and functioning, des-
matter of cognitive style. All three factors must be pite his advanced intellect and achievement, was
considered in the intervention process. Recogniz- consistent for what at that time was referred to as
ing that ADHD is a biopsychosocial disorder Attention Deficit Disorder with Hyperactivity. In
affecting individuals differently but consistently the following year, John participated in counseling
throughout their life span shifts the focus from focusing on improving relationships with family
attempting to search for a cure to developing a members and developing a life direction. He subse-
balance between symptom management and the quently served a two year mission for his church
reduction of immediate problems, all the while and obtained a college degree. John married and at
building in resilience factors during the childhood this writing is the father of two children. He works
years. It is likely that this combination of interven- in a managerial position with a number of siblings
tions stands the best chance of leading to positive in a business started by his father. At 13 years of
longterm outcomes for adults with ADHD. age John reports that he is happy and satisfied with
The research literature on this condition during his life. He continues to take medication for his
the adult years, or for that matter on the risk condition with reported and observed benefits. He
xxii Preface
participates in intermittent counseling, focusing on My parents have been amazingly supportive and
specific work, family and life issues as they arise. understanding through the years. This is in contrast to
their desperation and frustration. From early on they
With the first author, John explored a contribution
knew there was a problem, but no one could give them
to this volume focused on sensitizing clinicians on
any answers. As a child they sent me to a psychiatrist at a
his view of what those who profess to help adults time when it was a financial stretch, only to have him
with ADHD must know as well as his personal finally conclude that, while there was a real problem,
perception of the factors and forces that have there was nothing that he could do for me! Even when
times were the darkest, and my actions brought our
made a positive difference in his life. His words
family to the brink of chaos, their thoughts were on
follow.
how to help me. I really didn't understand all the time,
effort, and patience that they put into helping me. I was a
First, let me start off by dispelling the myth that
terror. Not intentionally, I just was quick to react and
ADHD is a blessing. It is not. Nor is it an advantage,
unaware of my own strength. I could usually pass for
gift, or desirable in any way. Any professional perpetuat-
several years older than I actually was, and that size
ing this myth possesses only knowledge derived from
coupled with a faulty think-before-you-act chip resulted
textbooks about this condition. Such an individual
in lots of bruises and tears for my siblings, and conse-
lacks sufficient understanding and empathy to counsel
quently me.
(much less treat) afflicted individuals. Strong words, be-
cause I believe strongly and want to make certain this is In the end, structure and guidelines in a loving,
understood above all else. Let me expand on this by caring, stimulating environment helped me above all
sharing an experience I had with my therapist. else, due to the limits my parents helped me set and
enforce. No single element could do it for me. I required
My therapist has told me on many occasions that I
the package. I have come to a point that I think I know
am what every ADHD therapist hopes for in their pa-
where the answer lies, but I challenge you the professional
tients. I have had a very difficult time accepting this. How
to find the answer. I believe the secret to combating
can someone with my history be the standard for achieve-
ADHD is the building of internalized barriers. An in-
ment for a class of people? Perhaps my list of "haves"
struction set that will not be broken. This is not easy.
gives some insight into the comment. As he has reminded
Pavlovian theory goes out the window with ADHD, as
me I have a loving wife, wonderful children, and a fully
does reason. Even positive and negative reinforcement
functional family that loves me. I have no chemical de-
are of little or no use. That is the dilemma.
pendencies, legal or otherwise, nor have I ever. I am
financially adequate. I have a degree in marketing, and, In my experience barriers are what insulate and pro-
subsequently, have a good job in which I do well and find tect someone with ADHD. Unfortunately, those barriers
great satisfaction. I am active, and devout in my faith. I are monumentally difficult to build and enforce. My
am in general a productive reasonably well-adjusted request of clinicians and professionals who deal with
member of society. ADHD and like disorders, si to help us (those with
ADHD) learn how to construct and be guided by those
All of that sounds really nice. I can hear, "Oh, there's
barriers. Without this understanding, knowledge and
a really together successful guy, by any standard." In that
insight, all therapy is hit-and-miss and lacks real, long-
context I will have to gratefully agree. Unfortunately this
term efficacy.
all belies the issues that don't come up in such a shopping
list. I am horribly disorganized, both at work and home. I This text represents a culmination of over forty-
have a tremendously difficult time completing the tasks five years of our work in this field. Our publica-
before me without succumbing to major tangential dis-
tions have included multiple texts (Goldstein &
tractions. I find it nearly impossible to do simple things
Goldstein, 1990, 1998; Goldstein, 1997; Teeter,
that I know are necessary, from getting places on time to
completing ordinary daily tasks. My marriage gets 1998), chapters (Goldstein, 1999; Goldstein &
strained to near breaking at times due to my inability to Ingersoll, 1993) and research articles on ADHD
stay in a conversation or project reliably. When I do find throghout the life span. One can measure the evo-
something that peaks my interest, all else will get pushed
lution of a clinical condition by the publication of
aside to make room for it, no matter how trivial it is.
volumes devoted to specific aspects of the condi-
Even in print these problems don't appear as dire as they
are experienced. tion. We believe the time has come for a text
Preface xxiii
devoted specifically to the treatment of ADHD in hope that this text will offer professionals a bal-
adulthood. Though this text is certainly a work in anced view of promising techniques combined with
progress and much research continues to be the skilled application of treatment methods con-
needed, it is our belief that this text offers a forming to accepted community standards and the
reasoned and reasonable review of the literature, responsible interpretation of clinical science. Know-
a practical set of clinical guidelines and the obser- ledgeable, compassionate professionals offer their
vations and insight of respected professionals who clients and patients a powerful sense of hope by
have devoted their careers to the scientific research providing accurate information, understanding,
and clinical treatment of this condition. It is our support and most importantly, treatment.
Sam Goldstein, Ph.D.
Ann Teeter Ellison, Ed.D.
SECNEREFER
Barkley, R. .A (1991). Attention deficit hyperactivity disorder: A Goldstein, .S & Ingersoll, .B Controversial treatments for chil-
lacinilc workbook. New York: Guilford press. dren with ADHD and impulse disorders. In .L F. Koziol,
Carey, .W .B (1988). A suggested solution to the confusion in .C .E Stout, & D. H. Ruben, (Eds.) (1993). Handbook of
attention deficit diagnoses. Clinical Pediatrics, ,72 348-349. doohdlihc impulse disorders and ADHD; Theory and practice.
Goldstein, .S (1997). Managing Attention Disorders and Learn- Springfield, IL: Charles .C Thomas.
gni Disabilities ni Late Adolescence and Adulthood. New Goodman, .L .S & Gilman, .A (Eds.). (1975). The pharmaco-
York: Wiley. logical basis of therapeutics 5( ht ed.). New York: Macmillan.
Goldstein, .S .)9991( Attention deficit hyperactivity disorder. In Greenhill, .L .L & Osman, .B .B (2000). Ritalin: Theory and
.S Goldstein & .C Reynolds (Eds.), Handbook of Nenrodeve- practice 2( dn ed.). Larchmont, NY: Mary Ann Liebert.
lopmental and Genetic Disorders. New York: Guilford press. Papazian, .O (1995). The story of fidgety Philip. International
Goldstein, .S & Goldstein, M. (1990). Educating Inattentive Pediatrics, ,01 .091-881
Children. Salt Lake City, UT: Neurology, Learning and ,llitS G. F. (1902). The Coulstonian lectures on some abnormal
Behavior Center. physical conditions in children. Lancet, ,1 .2101-8001
Goldstein, .S & Goldstein, M. (1998). Managing Attention Def- Teeter, .P .A (1998). Interventions for ADHD: Treatment ni
icit Hyperactivity Disorder: A Guide for Practitioners (2nd developmental context. New York: Guilford press.
ed.). New York: Wiley.
1
nA weivrevo fo doohdlihC dna
tnecselodA :DHDA
Understanding the Complexities of Development
into the Adult Years
Anne Teeter Ellison
To understand and treat attention deficit hyper- serious driving accidents were found at a higher rate
activity disorder (ADHD) in adulthood it si import- in individuals with ADHD than in a control group
ant to view the disorder from a developmental (Barkley, Murphy, & Kwasnik, 1996).
perspective (Teeter, 1998). According to longitudinal In an effort to establish a developmental link for
studies, a majority of adults with ADHD (70-85%) ADHD from childhood into adulthood, this chapter
who were diagnosed earlier in life continue to meet presents an overview of ADHD in childhood and
the diagnostic criteria of ADHD into adolescence adolescence. First, a transactional model for under-
and adulthood (Barkley, Fischer, Edelbrock, & standing how biogenetic, neuropsychological, cog-
Smallish, 1990; Biederman, Faraone, Milberger, nitive, and psychosocial factors interact and affect
Guite, et al., 1996; Gittelman, Manuzza, Shenker, & the overall adjustment of individuals with ADHD si
Bonagura, 1985; Ingram, Hechtman, & Morgen- advanced. The impact of environmental and cultural
stern, 1999; Weiss & Hechtman, 1993). Furthermore, factors si also explored. Second, a developmental
outcome data suggest that ADHD in childhood si a framework for ADHD si presented in which charac-
risk factor for significant psychiatric, psychosocial, teristics and associated features that appear early
and college or work adjustment difficulties later in and persist into adulthood are summarized. Third,
life (Barkley, 1998a; Satterfield & Schell, 1997; Weiss risk and resiliency factors are explored in an effort to
& Hechtman, 1993). Lower educational achieve- identify variables that either enhance or impede the
ment, felony arrest, substance abuse, early and fre- adjustment of individuals with ADHD. Finally,
quent sexual experimentation, social isolation, and issues that impact treatment are discussed.
Clinician's Guide to Adult ADHD:
Assessment and Intervention Copyright 2002, Elsevier Science (USA).
ISBN: 0-12-287049-2 All rights reserved.
2 Anne Teeter Ellison
LANOITCASNART LEDOM :DHDAFO TCAPMI 1997; Teeter, 1998; Barkley, 1997). See Figure 1.1
FO ,CITENEGOIB ,LACIGOLOHCYSPORUEN for a depiction of these interrelated factors.
,EVITINGOC DNA LAlCOSOHCYSP STICIFED
Biogentic Findings
Tannock (1998) asserts that "ADHD si a para-
digm for a true biopsychosocial disorder, raising Family transmission of ADHD has been sup-
critical questions concerning the relations between ported by a number of studies (Faraone & Bieder-
genetic, biological, and environmental factors" (p. man, 1994). The rate of ADHD in children of parents
65). Various transactional models of ADHD have with ADHD si higher than for the rate of ADHD in
explored the interaction of biogenetic vulnerabil- other relatives (Biederman et al., 1995). A parent
ities, executive control deficits, and the psycho- with ADHD has a 57% chance of having an ADHD
social and behavioral manifestations of the child. Adoption studies (Cantwell, 1975), twin
disorder (see Teeter and Semrud-Clikeman, 1995, studies (Gilger, Pennington, & DeFries, 1992),
~ Environmental Factors
~CNS
Biogenetic Factors Prenatal/neonatal toxins or insult
Birth complications
Temperament ~~Parental ygolohtapohcysp
Development & Maturation
I Prefrontal Cortex
Lower Brain Regions~Brain Stern & i I Executive gninoitcnuf
Thalamic Loop Behavioral inhibition
Initiation & regulation of motor control
Undifferentiated activation of cortex
Conscious direction of attention
Filtering incoming stimuli
Basal Ganglia/Limbic Bidirectional Feedback Coordination of actions
Mechanisms
Alerting/arousal
Thalamocortical Loop
Bottom-up sensory control / I ~ / ~ _ ~ ~ ~'''" "~
- - - ~ _~ Cognitive, Attentional &

.............. Perceptual Capacity

fo
I Behavioral Social, & Psychological Manifestations ADHD I
Relationship: Parents~Teacher Relationship: Peers Psychological
Strained Isolated Increased conduct problems
Oppositional detcejeR < Increased depression & anxiety
Defiant derongI Increased mood disorders
ERUGIF 1.1 lanoitcasnarT ledoM rof .DHDA