This presentation addresses psychotherapuetic treatment of attention-deficit/hyperactivity disorder in adults. A brief overview is presented of the current conceptualization of this disorder in the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). A brief discussion is set forth regarding mental health counseling therapies that have demonstrated effectiveness in helping adults to cope and improve social and occupational functionality. This presentation might be useful as an introduction to psychotherapeutic treatment of ADHD in adults, particularly within an undergraduate or lower-level graduate course in psychology or mental health counseling.

1. Evidence-Based Counseling Therapies
for Attention-Deficit/Hyperactivity Disorder
in Adults
Jeffrey A. Ahonen

2. 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).

3. 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).

4. 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).

5. 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)

6. 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).

7. 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).

8. 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).

9. 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).

10. 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).

11. 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 byVidal-
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

12. 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 ofADHD 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

13. 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
Therapy
and
Family
Therapy

14. 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.

15. References
American 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.

16. References
Kolar, D., Keller, A., Golfinopoulos, M., Cumyn, L., Syer, C., & Hechtman, L.
(2008).Treatment of adults with attention-deficit/hyperactivity disorder.
Neuropsychiatric Disease andTreatment, 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/s12402-010-0045-8
Maddux, J. E., &Winstead, B. A. (2012). Psychopathology: Foundations for a
contemporary understanding (3rd ed.). NewYork, NY: Routledge.
Paris, J., Bhat,V., &Thombs, B. (2015). Is adult attention-deficit hyperactivity
disorder being overdiagnosed? CanadianJournal of Psychiatry, 60(7), 324–
328.