A Conversation With Russell A. Barkley, PhD, About Adult ADHD 

 

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Russell A. Barkley, Ph.D., is a Clinical Professor of Psychiatry at the Virginia Treatment Center for Children and Virginia Commonwealth University Medical Center. He holds a Diplomate (board certification) in three specialties: Clinical Psychology, Clinical Child and Adolescent Psychology, and Clinical Neuropsychology.  Dr. Barkley is a clinical scientist, educator, and practitioner whose publications include 22 books, rating scales, and clinical manuals, 7 award-winning DVDs, and more than 260 scientific articles and book chapters related to the nature, assessment, and treatment of ADHD and related disorders.  He is also the founder and Editor of the clinical newsletter, The ADHD Report, now in its 24th year of publication.  Dr. Barkley has presented more than 800 invited addresses internationally and appeared on nationally televised programs such as 60 Minutes, the Today Show, Good Morning America, CBS Sunday Morning, CNN, and many other television and radio programs to disseminate the science about ADHD.  He has received awards from the American Psychological Association, American Academy of Pediatrics, American Board of Professional Psychology, Association for the Advancement of Applied and Preventive Psychology, the Wisconsin Psychological Association, and Children and Adults with ADHD (CHADD) for his career accomplishments, contributions to ADHD research and clinical practice, and for the dissemination of science about ADHD.  His websites are www.russellbarkley.org and ADHDLectures.com. 

shh_headshot-smallBy Susan Herman

Did you know that adults can have ADHD? It’s true—ADHD is not confined to children and teens.

The trademarks of Attention Deficit Hyperactivity Disorder (ADHD) are inattention, combined (for some) with hyperactivity and/or impulsive behaviors. According to the National Institutes of Mental Health, some people with ADHD only have problems with one of the behaviors, while others have both inattention and hyperactivity-impulsivity. It is normal to have some inattention, unfocused motor activity and impulsivity, but for people with ADHD, these behaviors are more severe, occur more often, and interfere with or reduce the quality of how they function socially, at school, or in a job…Children and adults with ADHD need guidance and understanding from their parents, families, and teachers to reach their full potential and to succeed.

Professor, researcher, and clinician Russell A. Barkley recently published a self-help book with APA LifeTools for family members of adults with ADHD, titled When an Adult You Love Has ADHD: Professional Advice for Parents, Partners, and Siblings. You can find more information about the book and purchase it here.

I recently interviewed Dr. Barkley about his work with adults who have ADHD, and how loved ones in their inner circle can support them.

How recently was adult ADHD recognized? 

A German-language textbook published in 1775 has a remarkably accurate description of what we now call ADHD in adults. But, aside from very periodic mentions in the literature—as “minimal brain dysfunction” in the 1950s, and as “hyperkinetic reaction” or “hyperkinetic disorder” in the 1960s—neither the public nor the research community much recognized it. It wasn’t until the 1970s that a series of longitudinal studies was conducted to find out whether ADHD continued beyond childhood. Interest in this picked up throughout the 1980s and 1990s as it was found that half to two-thirds of kids who were diagnosed with ADHD continued to have symptoms into their twenties. This was the first real evidence base that began to show us how ADHD, like mental retardation, dyslexia, and autism, can continue into adulthood.

What would you say has been your greatest contribution to the field of adult ADHD?

In 1991 I started an adult ADHD research clinic at University of Massachusetts Medical School, and the same year my psychiatrist colleague Joe Biederman started one at Massachusetts General Hospital in Boston. We were collecting data on a variety of domains of impairment and symptoms on these adults to see if it was equivalent to the childhood form of the disorder – it clearly was.  Later, Alan Zametkin and colleagues at the NIMH did the first PET scan study showing brain related deficits in functioning in adults with ADHD.  Other studies on never-before-diagnosed adults were done to learn whether they responded to the same types of drugs that children were being given for ADHD.  Results showed that they did so.

In 2008 I published a monograph where I compared results of my own 20-year longitudinal studies on children with ADHD followed to an average age of 27.  Drs. Kevin Murphy and Mariellen Fischer and I compared them with adults diagnosed with ADHD alongside data I’d been collecting in the

clinic from adults who were not diagnosed as ADHD. This was the first time anyone had compared the two groups directly (children with ADHD grown up vs. adults diagnosed with ADHD). The monograph was massive, but I chose that format over journals because with journal articles you have page limitations and you have to peel off tiny bits of your research and present it over multiple, disparate articles. Instead I presented it all at once, and this allowed adult ADHD to really hit the research map. Others followed up my work with various methods of neuroimaging to show differences in brain activity for adults with ADHD.

Why did you decide to focus on parents, siblings, and partners of people with ADHD in your latest book?

Ever since I wrote a self-help book for adults who have ADHD, called Taking Charge of Adult ADHD (in 2010), I’d been wanting to write one for the family members who support them. At the time there was no science-based trade book available for loved ones of people with ADHD. Also, ADHD is in my family. I had been trying to help various of my own family members, get them treatment and offer a safety net, so I knew there were others out there also feeling frustrated after picking up and dusting off their loved one again and again.

I was ready to write the book when my twin brother died. He had ADHD, and I know that it indirectly contributed to his death. He was driving 40 miles per hour on a country road in the Adirondacks. He never wore a seatbelt, and he had a habit of going too fast and drinking while driving. He ran off the road and was killed. I put the book aside while I was grieving him. Not long after my sister, who had physical disabilities, also died. And about three years after that, my deceased brother’s son, who also had ADHD, hanged himself.  So I just “couldn’t go there” for a while due to all this grieving.

Finally, in 2015 the time was right. Several books on how ADHD affects marriage had appeared by that time. Writing about how to love someone with ADHD was cathartic for me. I feared that re-living events would make me feel worse, but actually I felt better.

Thank you for sharing that personal story. I’m glad you decided to include some of it in the book, too. 

adult-adhdLet’s back up a bit and talk about how ADHD can affect adults who have it. Also, how many adults have ADHD—how common is it in the population?

Four to five percent of adults in the USA have ADHD. The percentage is closer to 3-4% worldwide. It’s higher in Western countries because of longer life expectancy and better access to care. In children the ratio of boys to girls with ADHD is three to one; for adults there’s less of a split; it’s closer to 1.4 to 1 male to female. It’s been great seeing more women come out of the woodwork to talk about ADHD. I recently consulted on articles in Elle, Glamour, and Cosmopolitan magazines about adult ADHD.

ADHD is genetic in about two thirds of all cases; in about one third it is acquired either prenatally or after birth because of head trauma or environmental conditions that affect the brain’s frontal lobe development.

Adults who have ADHD typically achieve a lower level of education than they are capable of, and they have problems in the workplace with boring tasks that require sustained attention. Adults with ADHD tend to do well in non-traditional careers, often those that involve performing, music, athletics, police work, and the military. There are people with ADHD in law and medicine, but fewer than you’ll find in the more physically active careers.

Money management is a challenge for many people who have ADHD, as is driving. Adults with ADHD are 2-3 times more likely to be dead by age 46 from accidental injuries, many of which involve driving. About one third of adults with ADHD exhibit antisocial behavior and may even get involved with crime.

New research areas in adult ADHD include risky sexual behavior, along with marriage and parenting problems. ADHD is really one of the most impairing outpatient disorders there is—I would venture to say it’s even more impairing than depression—because it affects so many diverse areas of life. Clinical care and family counseling for adult ADHD exists and is increasingly available but is far from where it needs to be. As of ten years ago, only about one in ten adults with ADHD was diagnosed. The percentage is better now but there is still much progress to be made.

What do family members and partners need to understand about ADHD to best support their loved one who has it?

It’s important to adopt a biologically-based view of ADHD. ADHD is a neuro-genetic disorder. You can’t attribute your loved one’s behaviors to personality quirks, defective morality, laziness, or poor lifestyle choices or say they deserve whatever they get. You can’t be a good support person if you keep thinking, “My loved one could change if they wanted to, but they don’t want to.” People in the inner circle are their loved one’s best safety net and closest influence, but they can’t step up as stakeholders if they don’t adopt a more compassionate outlook about ADHD.

What kinds of support can family members provide to an adult who has ADHD? 

In my clinical work I walk through six steps with adults who have ADHD and their families. Step One is to get a thorough mental health evaluation to document not only ADHD, but any other disorders that the person might also have. Eighty percent of adults with ADHD have an additional disorder, and about half have two additional disorders. These might be anxiety, depression, a learning disability, bipolar, or something else. Detecting secondary disorders affects the course of ADHD treatment. Psychologists, psychiatrists, and behavioral neurologists can diagnose ADHD.

So the support person might offer to set up various appointments for their loved one and help them follow through getting to the specialist’s office.

Yes.

Step Two is to help the patient “own” their ADHD as a part of their identity. It’s easier to accept a diagnosis intellectually than it is to incorporate it as a part of your own view of yourself. Treatment will be superficial if the person doesn’t accept ADHD as a part of their self-view. When the patient starts to grieve their old self-image, that’s when we know we are getting through. Accepting the new you is also a positive thing because it means you’re giving up the old view of yourself as stupid, lazy, or immoral.

Step Three is to read widely and educate yourself about ADHD. I like to say that “truth is an assembled thing.” You can’t just depend on one source for all your information. Jeff Copper’s podcast, Attention Talk Radio, is a great resource, and I offer many more in the book. Think about it: if you’re diabetic, you have to understand how diet plays into your condition, and hygiene [for blood tests and insulin monitoring], and a host of other things. Because ADHD is a chronic disease I sometimes refer to it as the diabetes of psychiatric conditions.

Step Four is to get on medication. Medication is the best treatment for ADHD. And I’m saying this as a psychologist—there is no longer any “us versus them” going on between psychologists [who typically do not prescribe medication] and psychiatrists when it comes to ADHD treatment. Medication is two to three times more effective than behavioral methods alone for treating ADHD. Most adults with ADHD, 80-90%, need medication as part of the treatment package. Family members can help their loved one remember to take their ADHD medication regularly.

Step Five is behavior modification. Cognitive behavioral therapy (CBT) boosts the benefits of ADHD medication for self-control and executive functioning. Outside of formal therapy, there’s a lot family members can do to encourage their loved one to adopt exercise routines and other healthy habits. Often times people with ADHD need to get additional treatment to cut back or eliminate their use of alcohol, tobacco, and marijuana.

Step Six is accommodation. This means altering the environment so the person with ADHD is more likely to succeed. It might mean dedicating one computer for work only and another one for games and social networking. Family members can help their loved one find and download software that blocks distracting content. At home and on the job, adults with ADHD can advocate for themselves by finding support people to keep them accountable for changes they want to make and goals they want to accomplish.

A new type of accommodation that’s becoming more popular is called ADHD coaching. An ADHD coach makes daily contact via text or other channels to help the person stay organized, cope with frustration, and/or work through social problems. The field of ADHD coaching is still developing and is beginning to police itself. Some people are coming to ADHD coaching from financial planning or life coaching and are not currently held to a specific standard of knowledge or experience within psychology or behavior modification. I expect within five years certification requirements and accreditation for ADHD coaching will be in place.

 

Note: The opinions expressed in this interview are those of the author and should not be taken to represent the official views or policies of the American Psychological Association.

 

October Releases From APA Books!

language-autismInnovative Investigations of Language in Autism Spectrum Disorder

Edited by Letitia R. Naigles

In recent decades, a growing number of children have been diagnosed with autism spectrum disorder (ASD), a condition characterized by, among other features, social interaction deficits and language impairment. Yet the precise nature of the disorder’s impact on language development is not well understood, in part because of the language variability among children across the autism spectrum. The contributors to this volume—experts in fields ranging from communication disorders to developmental and clinical psychology to linguistics—use innovative techniques to address two broad questions: Is the variability of language development and use in children with ASD a function of the language, such that some linguistic domains are more vulnerable to ASD than others? Or is the variability a function of the individual, such that some characteristics predispose those with ASD to have varying levels of difficulty with language development and use?

 

supervision-emotion-focusedSupervision Essentials for Emotion-Focused Therapy

by Leslie S. Greenberg and Liliana Ramona Tomescu

The authors introduce a model of supervision that is founded on the fundamental principles of emotion-focused therapy (EFT): a safe supervisory alliance and relationship, an agreed-upon focus for each supervision session, and the identification of appropriate task markers (moments of uncertainty that present opportunities for supervisory intervention). Together, EFT supervisors and supervisees carefully deconstruct recorded therapy sessions, with moment-by-moment processing of the supervisee’s responses and emotional understanding.  Through close observation, supervisors enable trainees to develop seeing, listening, and empathic skills, as they become more attuned to both verbal and non-verbal cues that indicate clients’ emotional responses.

 

 

supervision-integrativeSupervision Essentials for Integrative Psychotherapy

by John C. Norcross and Leah M. Popple

This book presents integrative supervision applicable to integrative and single-system psychotherapy alike. Distinctive features include its synthesis of supervisory methods aligned with multiple theoretical traditions, a research-informed fit of supervision to the individuality of the supervisee, its insistence on frequent feedback from both clients and trainees, and a modeling of the philosophical pluralism and pragmatic flexibility of integration itself. In reviewing videotaped therapy sessions, integrative supervisors offer key insights into common problems, demonstrate how to adjust treatment to clients’ transdiagnostic needs, and guide trainees to clinical competence.

 

  

trauma-meaning-spiritualityTrauma, Meaning, and Spirituality

Translating Research into Clinical Practice

by Crystal L. Park, Joseph M. Currier, J. Irene Harris, and Jeanne M. Slattery

Trauma represents a spiritual or religious violation for many people. Survivors attempt to make sense out of painful events, incorporating that meaning into their current worldview in either a harmful or a more helpful way. This volume helps mental health practitioners—many of whom are less religious than their clients—understand the important relationship between trauma and spirituality, and how to best help survivors create meaning out of their experiences.  Drawing on relevant theories and research, the authors present a new conceptual framework, the Reciprocal Meaning-Making Model, demonstrating how it can guide both assessment and treatment. Through the use of case material, the authors examine a range of spiritual views, traumas, and posttraumatic reactions that are reflective of the population as a whole rather than targeting only specific religions or cultural perspectives.   Given the lack of scientific literature on the topic, this book fills an important gap, and will appeal to clinicians and researchers alike.

Open Pages: Womanist and Mujerista Psychology

APA Books Open Pages is an ongoing series in which we share interesting tidbits from current & upcoming books. Find the full list by browsing the Open Pages tag. Here, we check out the introduction of Womanist and Mujerista Psychologies: Voices of Fire, Acts of Courage to find out what, briefly, these lesser-known terms mean:

“The term womanist was coined by Walker (1983): ‘a Black feminist or feminist of color committed to the survival and wholeness of entire people, male and female. Not a separatist, except periodically for health’ (p. xi). In other words, in addition to centralizing survival and wholeness of women and men, a womanist does not create a hierarchy between the rights against racism and sexism but sees both of these fights as necessary and central. Womanism is a sociopolitical framework that centralizes race, gender, class, and sexuality as central markers of women’s lived experiences (Brown-Douglas, 1993). It moves beyond the compartmentalizing of Black women’s experience as is often seen in feminism and multiculturalism and moves toward an integrated perspective and analysis.” (pp. 5-6).

“As a construct, mujerismo (from the Spanish word mujer, meaning woman) emerged when Latina feminist theologians baptized themselves as mujeristas (Isasi-Diaz, 1994). Mujerismo is Latina womanism (Comas-Diaz, 2008; Meija et al., 2013; Ojeda, 2014). Indeed, the conceptual and political translation of womanist into Spanish is mujerista…like womanists, mujeristas embrace an interdisciplinary perspective. They endorse inclusion as an essential ingredient for the movement’s continual development. In this way, diverse voices are not only welcomed but also sought after.” (pp. 7-8).

 

Bryant-Davis, T., & Comas-Diaz, L. (2016). Womanist and Mujerista Psychologies: Voices of Fire, Acts of Courage. Washington, DC: American Psychological Association.

Living With Fear: Terror Management Theory

by Trish Mathis

Recently, I was riding to work on a commuter train when I noticed a briefcase on a seat nearby, unattended. I set my book on my lap and glanced around, but the item didn’t seem to belong to anybody. Although it looked innocuous lying there, I knew better. The many safety warnings about unattended baggage I’d heard broadcast over the station platforms and in airport concourses since 9/11 all buzzed in my ears simultaneously. It must be a bomb.

briefcaseIt suddenly felt very hot and I struggled out of my coat, frantically looking for the conductor. I bit my lip and resisted the urge to get up and run into the next train car. My right leg jiggled up and down seemingly of its own accord and I shifted to the edge of my seat, wondering what to do as the breath caught in my throat. I closed my eyes and hoped that everything would be fine, that we would all make it safely through the morning grind.

Just then, a man stepped into my car from the next one, walked down the aisle, and sat in the seat with the briefcase. He clicked it open, removed a folder, and calmly began reading the pages inside. As my surge of adrenaline drained away, I felt very foolish. Of course there was no bomb. That person probably just had to use the train’s restroom, and who takes a briefcase in there?

Where did my fear come from? According to the APA Dictionary of Psychology, terror management theory (TMT) proposes that “control of death anxiety is the primary function of society and the main motivation in human behavior. Accordingly, awareness of the inevitability of death motivates people to maintain faith in the absolute validity of the beliefs and values that give their lives meaning….” This model explains why we react the way we do to the threat of death and describes how this reaction influences our thoughts, emotions, and actions. Introduced in 1984 by social psychologists Jeff Greenberg, Sheldon Solomon, and Tom Pyszczynski, TMT has become a prominent part of their research. They have published widely on the subject, notably including the APA title In the Wake of 9/11: The Psychology of Terror. (Also check out The Psychology of Hate and Understanding Terrorism: Psychosocial Roots, Consequences, and Interventions.)

psych-of-terrorAlthough death anxiety can be activated by even the most mundane daily events and moments, TMT is also useful for understanding the fears generated by our current sociopolitical climate. We constantly hear media reports about ISIS, see threatening videos splashed across the Internet, and watch news footage of innocent civilians killed by bombs in Spain or shot by gunmen in Paris. Remember the anthrax attacks perpetrated through the U.S. mail in Washington, DC, several years ago? Do you still experience the occasional twinge of apprehension when opening an unexpected letter or package? We can’t help but worry that we might be the next victim.

And so perhaps we decide not to attend a crowded sporting event one day. We cancel a long-anticipated trip the next. We glare suspiciously at strangers on the streets. Yet simultaneously, we proudly hang American flags from our front porches and we donate to charities. Indeed, as Greenberg et al. noted in the introduction of their most recent book The Worm at the Core: On the Role of Death in Life, “the fear of death is one of the primary driving forces of human action.” At the end of the day, we use our traditions, beliefs, and values to give our lives meaning and thus obscure the anxiety created by our awareness of the possibility of death.

Of course, some of us are more successful at this than others. Fortunately, the theory’s originators offer some strategies for how to deal more productively with the anxiety potential threats produce. These include maintaining close connections with others, gathering information to understand an event, and enhancing self-esteem. Perhaps you’ve tried these ideas in some form or another, and perhaps like me, you have a specific approach you find most helpful.

So the next time I see unattended baggage during my commute, maybe I’ll panic again as the prospect of my own mortality slams into focus. But then I’ll remind myself that my response is a natural, inevitable part of being human. When the immediate danger passes, I can return to the sanctuary offered by routine: the book I’m reading on the train, the susurration of passenger conversation around me, and the normalcy of going to work to do something I consider worthwhile.

 

References

Moghaddam, F. M., & Marsella, A. J. (2004). Understanding terrorism: Psychosocial roots, consequences, and intervention. Washington, DC: American Psychological Association.

Pyszczynski, T., Solomon, S., & Greenberg, J. (2003). In the wake of 9/11: The psychology of terror. Washington, DC: American Psychological Association.

Solomon, S., Greenberg, J., & Pyszczynski, T. (2015). The worm at the core: On the role of death in life. New York, NY: Random House.

Sternberg, R. J. (2005). The psychology of hate. Washington, DC: American Psychological Association.

VandenBos, G. R. (Ed.). (2015). APA dictionary of psychology (2nd ed.). Washington, DC: American Psychological Association.