Workbook for ADHD in Adults Workbook By Julie Guillemin, MSW, LICSW Upon successful completion of this course, continuing education hours will be awarded as follows: Social Workers, Counselors, Marriage and Family Therapists: 4 Clock Hours
WESTERN SCHOOLS P.O. Box 1930 Brockton, MA 02303 800-438-8888 ABOUT THE WORKBOOK AUTHOR Julie Guillemin, MSW, LICSW, earned her MSW from the Boston University School of Social Work. She is currently in private practice at Levin & Zangrillo, P.C., where she works with children, adolescents, adults, and families, addressing adjustment problems, psychiatric disorders, behavioral issues, and learning disabilities. Ms. Guillemin has worked with toddlers, children, and adolescents and their families in private and public school settings, providing individual and group therapy and social skills instruction. She has extensive experience working with individuals with attention-deficit hyperactivity disorder (ADHD). Ms. Guillemin collaborates with pediatricians, teachers, and other service providers to enhance the treatment experience of children and adolescents with ADHD and other disorders. Julie Guillemin has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. Behavioral Health Planners: Lys Hunt, MSW, LICSW, and Elizabeth Russell, MSW, PhD The planners who worked on this continuing education activity have disclosed that they have no significant financial or other conflicts of interest pertaining to this course book. Copy Editor: Diane Hinckley Western Schools courses are designed to provide healthcare professionals with the educational information they need to enhance their career development as well as to work collaboratively on improving patient care. The information provided within these course materials is the result of research and consultation with prominent healthcare authorities and is, to the best of our knowledge, current and accurate at the time of printing. However, course materials are provided with the understanding that Western Schools is not engaged in offering legal, medical, or other professional advice. Western Schools courses and course materials are not meant to act as a substitute for seeking professional advice or conducting individual research. When the information provided in course materials is applied to individual cases, all recommendations must be considered in light of each case s unique circumstances. Western Schools course materials are intended solely for your use and not for the purpose of providing advice or recommendations to third parties. Western Schools absolves itself of any responsibility for adverse consequences resulting from the failure to seek medical, or other professional advice. Western Schools further absolves itself of any responsibility for updating or revising any programs or publications presented, published, distributed, or sponsored by Western Schools unless otherwise agreed to as part of an individual purchase contract. Products (including brand names) mentioned or pictured in Western Schools courses are not endorsed by Western Schools, any of its accrediting organizations, or any state licensing board. ISBN: 978-1-68041-186-7 COPYRIGHT 2016 S.C. Publishing. All Rights Reserved. No part(s) of this material may be reprinted, reproduced, transmitted, stored in a retrieval system, or otherwise utilized, in any form or by any means electronic or mechanical, including photocopying or recording, now existing or hereinafter invented, nor may any part of this course be used for teaching without written permission from the publisher. FP0816WS ii
COURSE INSTRUCTIONS IMPORTANT: Read these instructions BEFORE proceeding! HOW TO EARN CONTINUING EDUCATION CREDIT To successfully complete this course you must: 1) Read the entire course 2) Pass the final exam with a score of 75% or higher* 3) Complete the course evaluation *You have three attempts to pass the exam. If you take the exam online, and fail to receive a passing grade, select Retake Exam. If you submit the exam by mail or fax and you fail to receive a passing grade, you will be notified by mail and receive an additional answer sheet. Final exams must be received at Western Schools before the Complete By date located at the top of the FasTrax answer sheet enclosed with your course. Note: The Complete By date is either 1 year from the date of purchase, or the expiration date assigned to the course, whichever date comes first. HOW TO SUBMIT THE FINAL EXAM AND COURSE EVALUATION ONLINE: best option! For instant grading, regardless of course format purchased, submit your exam online at www.westernschools.com/my-courses. Benefits of submitting exam answers online: Save time and postage Access grade results instantly and retake the exam immediately, if needed Identify and review questions answered incorrectly Access certificate of completion instantly Note: If you have not yet registered on Western Schools website, you will need to register and then call customer service at 800-618-1670 to request your courses be made available to you online. Mail or Fax: To submit your exam and evaluation answers by mail or fax, fill out the FasTrax answer sheet, which is preprinted with your name, address, and course title. If you are completing more than one course, be sure to record your answers on the correct corresponding answer sheet. Complete the FasTrax Answer Sheet using blue or black ink only. If you make an error use correction fluid. If the exam has fewer than 100 questions, leave any remaining answer circles blank. Respond to the evaluation questions under the heading Evaluation, found on the right-hand side of the FasTrax answer sheet. See the FasTrax Exam Grading & Certificate Issue Options enclosed with your course order for further instructions. CHANGE OF ADDRESS? Contact our customer service department at 800-618-1670, or customerservice@westernschools.com, if your postal or email address changes prior to completing this course. WESTERN SCHOOLS GUARANTEES YOUR SATISFACTION If any continuing education course fails to meet your expectations, or if you are not satisfied for any reason, you may return the course materials for an exchange or a refund (excluding shipping and handling) within 30 days, provided that you have not already received continuing education credit for the course. Software, video, and audio courses must be returned unopened. Textbooks must not be written in or marked up in any other way. Thank you for using Western Schools to fulfill your continuing education needs! WESTERN SCHOOLS P.O. Box 1930, Brockton, MA 02303 800-618-1670 www.westernschools.com iii
Western Schools course evaluation ADHD IN ADULTS INSTRUCTIONS: Using the scale below, please respond to the following evaluation statements. All responses should be recorded in the right-hand column of the FasTrax answer sheet, in the section marked Evaluation. Be sure to fill in each corresponding answer circle completely using blue or black ink. Leave any remaining answer circles blank. A B C D Agree Agree Disagree Disagree Strongly Somewhat Somewhat Strongly OBJECTIVES: After completing this course, I am able to: 1. Explain the symptoms, epidemiology, and differential diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults. 2. Describe theories and models of ADHD in adults. 3. Identify issues involved in assessing and diagnosing ADHD in adults. 4. Differentiate treatment methods and challenges to treating ADHD in adults. 5. Analyze case studies of adults diagnosed with and treated for ADHD. COURSE CONTENT 6. The course content was presented in a well-organized and clearly written manner. 7. The course content was presented in a fair, unbiased and balanced manner. 8. The course content presented current developments in the field. 9. The course was relevant to my professional practice or interests. 10. The course material was appropriate to my education, experience, and licensure level. 11. The course expanded my knowledge and enhanced my skills related to the subject matter. 12. I intend to apply the knowledge and skills I ve learned to my practice. A. Yes B. Unsure C. No D. Not Applicable CUSTOMER SERVICE The following section addresses your experience in interacting with Western Schools. Use the scale below to respond to the statements in this section. A. Yes B. No C. Not Applicable 13. Western Schools staff was responsive to my request for disability accommodations. 14. The Western Schools website was informative and easy to navigate. 15. The process of ordering was easy and efficient. 16. Western Schools staff was knowledgeable and helpful in addressing my questions or problems. ATTESTATION 17. I certify that I have read the course materials and personally completed the final examination based on the material presented. Mark A for Agree and B for Disagree. v continued on next page
vi Course Evaluation ADHD in Adults COURSE RATING 18. My overall rating for this course is A. Poor B. Below Average C. Average D. Good E. Excellent 19. Choose the response that best represents the total number of clock hours it took you to complete this course. A. 3-5 Hours B. More than 5 hours C. Less than 3 hours 20. How much did you learn as a result of this CE program? 1 (A) 2 (B) 3 (C) 4 (D) 5 (E) Very Little Great Deal 21. How useful was the content of this CE program for your practice or other professional development? 1 (A) 2 (B) 3 (C) 4 (D) 5 (E) Not Useful Extremely Useful You may be contacted within 3 to 6 months of completing this course to participate in a brief survey to evaluate the impact of this course on your clinical practice and patient/client outcomes. Note: To provide additional feedback regarding this course, Western Schools services, or to suggest new course topics, use the space provided on the Important Information form found on the back of the FasTrax instruction sheet included with your course.
CONTENTS Course Evaluation...v Pretest...ix Introduction...xi Lesson Plan...1 Final Exam...3 vii
PRETEST 1. Begin this course by taking the pretest. Circle the answers to the questions on this page, or write the answers on a separate sheet of paper. Do not log answers to the pretest questions on the FasTrax test sheet included with the course. 2. Compare your answers to the answers in the pretest key located at the end of the pretest. The pretest key indicates the page where the content of that question is discussed within the textbook. Make note of the questions you missed, so that you can focus on those areas as you complete the course. 3. Read the entire course and complete the exam questions at the end of the course. Answers to the exam questions should be logged on the FasTrax test sheet included with the course. Note: Choose the one option that BEST answers each question. 1. ADHD is a neurodevelopmental disorder that a. can be mediated by therapy and medication. b. resolves by early adulthood if treated correctly. c. has consistent symptoms from childhood through adulthood. d. is overdiagnosed in the adult population. 2. ADHD in adults is thought to be caused by a. a history of family dysfunction. b. nutritional deficits during early developmental stages. c. interactions between dysfunctional parenting and educational environments. d. interactions among neurobiological, environmental, and psychosocial factors. 3. When assessing for ADHD, clinicians should keep in mind that a. direct observation is the primary source of information for support of a diagnosis. b. a thorough developmental history is crucial to confirm that impairment caused by symptoms was present prior to age 12. c. genetic testing is the most reliable source of information and should be recommended for every client prior to the clinical interview. d. family members generally provide more accurate information than clients. 4. Individuals who are diagnosed with ADHD in adulthood a. are most successfully treated with psychotherapy. b. usually see all of their symptoms resolve with medication treatment. c. are likely to experience impaired psychosocial functioning when untreated. d. experience little impairment in functioning in key life domains. ix continued on next page
x Pretest ADHD in Adults 5. Clinicians who treat adults with ADHD a. may use a variety of approaches, including cognitive behavior therapy, coaching, and the teaching of problem solving and coping skills. b. should prioritize medication referrals at the outset of treatment for higher functioning clients and those with children who have an ADHD diagnosis. c. have much greater success treating clients with comorbid disorders. d. typically lack necessary training and education about the disorder. PRETEST KEY 1. a Page 7 2. d Page 33 3. b Page 35 4. c Page 45 5. a Page 69
INTRODUCTION Course Objectives After completing this course, the learner will be able to: 1. Explain the symptoms, epidemiology, and differential diagnosis of attention-deficit/ hyperactivity disorder (ADHD) in adults. 2. Describe theories and models of ADHD in adults. 3. Identify issues involved in assessing and diagnosing ADHD in adults. 4. Differentiate treatment methods and challenges to treating ADHD in adults. 5. Analyze case studies of adults diagnosed with and treated for ADHD. Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder that emerges in childhood and may persist throughout the life span. ADHD affects an individual s social, emotional, academic, and professional functioning and is correlated with many psychosocial problems. Symptoms of the disorder can be disabling, making it difficult to succeed academically and socially and often causing emotional distress. Diagnosing ADHD is complicated by the similarity of the symptoms of ADHD to those of many other psychiatric, medical, developmental, and neurological disorders. Additionally, comorbidity rates are high for individuals with ADHD. Behavioral manifestations of ADHD differ among individuals, and clinicians need to use appropriate assessment tools in order to distinguish ADHD symptoms from those of other psychiatric disorders. Cultural considerations are also relevant and must be considered in assessment, diagnosis, and treatment approaches. Treatment options for ADHD include medication, psychotherapy, organizational training, coaching, and alternative treatments. Medications for ADHD are often effective but may have problematic side effects, including worsening comorbid disorders. This intermediate-level course offers social workers, mental health counselors, marriage and family therapists, and psychologists information that will assist them in assessing, diagnosing, and treating adults with ADHD. Diagnostic criteria are drawn from the DSM-5 and aligned to ICD-10 codes. A review of the different theories and models of ADHD provides the clinician with an understanding of environmental influences, genetic contributions, neurological issues, and psychological factors in ADHD. The essential components of assessing and diagnosing ADHD, including psychological testing, client history, and environmental and family influence are discussed. Diagnosis is explained, including the complexities involved in differential diagnosis and assessing for comorbid conditions. Methods of treatment are explored, including psychopharmacology, psychotherapy, coaching and psychoeducation, and treatments in combination. Research on treatment effects with adults is presented, allowing the clinician xi
xii Introduction ADHD in Adults to select appropriate, evidence-based treatments that can be tailored to individual clients. Issues encountered in treatment are examined. Two detailed case vignettes help learners apply newly acquired information to hypothetical client situations. The textbook identifies and describes support groups and organizations and provides their contact information. This course is an ideal reference for clinicians who encounter ADHD in adult clients in all settings, including hospitals, colleges, employee assistance programs, and mental health treatment centers. The course serves as a comprehensive resource to assist clinicians in understanding, assessing, diagnosing, and treating ADHD in adults.
lesson plan ADHD IN ADULTS This educational offering incorporates the information contained in ADHD in Adults by Brian P. Daly, Elizabeth Nicholls, and Ronald T. Brown into an integrated learning experience. Learning objectives for the course focus individual study on information contained within the textbook. The final examination questions are based on the learning objectives and are intended to evaluate the reader s learning of each objective. To complete this course, read the Table of Contents located in the front of the textbook to determine the scope of the content. Review the course objectives, then read each chapter in the textbook and answer the final examination questions (workbook pages 3-6) as indicated in this Lesson Plan. Answer final exam questions online at www.westernschools.com/mycourses for instant results, or log answers on the FasTrax answer sheet provided with the course. NOTE: Before getting started, log into your account at www.westernschools. com/my-courses to take your exam as you read the course. You can save your progress and return to it at any time. If completing by mail or fax, please be sure you are using the FasTrax answer sheet labeled ADHD in Adults. Chapter 1 Chapter 1 offers an overview of the symptoms and epidemiology of attention-deficit/ hyperactivity disorder (ADHD) in adults. The authors discuss prevalence, prognosis, comorbid disorders, correlates, presentation, and differential diagnosis issues. Chapter 1 describes the specific challenges involved in diagnosing ADHD in adults and suggests ways to strengthen the assessment. The authors describe the key elements of a systematic approach to gathering data. Different elements of a thorough assessment are presented, including diagnostic interviews, rating scales, psychoeducational testing, neuropsychological testing, and laboratory testing. Read and study Chapter 1 and answer questions 1-7. Chapter 2 In Chapter 2, the authors explain the theories and models of ADHD and explore the contributions of genetic and neurological factors, environmental factors, and psychosocial factors. Chapter 2 describes the physiological differences between people with and without ADHD and reviews neurological studies that explore how ADHD affects cognitive functioning. Read and study Chapter 2 and answer questions 8-11. 1
Lesson Plan 2 ADHD in Adults Chapter 3 Chapter 3 explores the assessment and diagnosis of ADHD. The authors offer guidance on gathering relevant information about the client s history and assessing the individual s level of functioning in different settings and his or her social and emotional issues. Specific rating scales and neuropsychological tests are compared. The intricacies of differential diagnosis are discussed. The authors present practical advice on obtaining the most accurate information and how to use test results to inform diagnosis. The ADHD diagnostic flowchart is introduced. Read and study Chapter 3 and answer questions 12-16. Chapter 4 Chapter 4 focuses upon treatment methods for ADHD, including research findings and statistical data on the effectiveness of different treatments. Psychopharmacological treatments, including stimulants and non-stimulants, are explored in depth. Dual diagnosis and comorbid conditions are explained as they relate to treatment planning. The authors discuss various treatments, including psychoeducation, cognitive behavior therapy, behavior therapy, coaching, and teaching organizational and coping skills. Guidelines on how to select, plan, and use different treatments are provided. Read and study Chapter 4 and answer questions 17-23. Chapter 5 Chapter 5 presents two case studies of individuals with ADHD. Diagnosis and treatment are explored, with attention to support systems and stressors. Read and study Chapter 5 and answer questions 24 and 25.
Final Exam ADHD in Adults Questions 1 25 Note: Choose the one option that BEST answers each question. 1. According to DSM-5 criteria, a diagnosis of adult ADHD requires a. a childhood onset of eight or more symptoms. b. two or more symptoms that are particularly severe. c. a combination of both hyperactive and inattentive symptoms that interfere with functioning. d. five or more symptoms that interfere with social, academic, or occupational functioning. 2. Once thought to be a childhood disorder, ADHD is becoming recognized as one of the most common psychiatric disorders in adults. The global prevalence of ADHD among adults is estimated to be a. 3.4%. b. 13.4%. c. 23.4%. d. greater than 33%. 3. Adults with ADHD usually experience a. symptoms of inattention. b. increased hyperactivity. c. symptoms in the same manner as children with ADHD. d. their ADHD symptoms for the first time in adulthood. 4. Because several conditions and disorders share certain signs and symptoms of ADHD, differential diagnosis is essential and, if appropriate, clinicians should a. diagnose each co-occurring condition separately. b. immediately refer clients for psychiatric evaluations. c. always prioritize ADHD treatment over all other conditions. d. delay any diagnosis of ADHD for 6 months. 5. The most common comorbid disorders among adults with ADHD are a. disruptive and conduct disorders. b. autism spectrum disorders. c. intellectual disabilities. d. anxiety and mood disorders. 6. According to research on gender-based differences in ADHD and comorbidity, which of the following disorders occurs more frequently in men with ADHD than in women with ADHD? a. Substance use disorders b. Anxiety disorders c. Mood disorders d. Eating disorders 3 continued on next page
Final Exam 4 ADHD in Adults 7. During assessment for ADHD and comorbid disorders, clinicians should obtain comprehensive data about a client by a. interviewing current employers and spouses or partners. b. locating the neurological cause of the client s impairment. c. using a variety of measures and sources across settings. d. relying on medical and educational records from the client s childhood. 8. According to researchers studying the pathophysiology of ADHD, neurological correlates of ADHD include a. a larger frontal cortex b. reduced overall brain volume. c. hyperactivity in several regions of the brain. d. a larger corpus callosum. 9. Compared to adults without ADHD, adults with ADHD tend to have a. enhanced goal-directed behavior. b. nutritional surpluses. c. a smaller family size. d. impaired verbal memory. 10. According to Russell Barkley s model of ADHD, poor behavioral inhibition a. is the central deficit of ADHD and a complex process that results in impulsivity, perseveration, and poor self-control. b. leads to deficits in simple alertness, long-term memory, and cognitive dissonance. c. causes ADHD, and is unrelated to neurocognitive and other causative factors. d. can be normalized in children and adults with ADHD via behavior therapy in inpatient and milieu settings only. 11. Evidence from recent studies suggests that the strongest single risk factor for ADHD is a. psychosocial. b. cultural. c. genetic. d. nutritional. 12. Clinicians assessing for ADHD in adults should a. assess for the presence of five symptoms in one setting. b. evaluate the level of functional impairment in important domains. c. administer clinician-rated scales rather than self-report rating scales. d. use direct observation rather than behavior scales. 13. Evidence suggests that childhood caregivers of adults with ADHD often a. exaggerate functional impairment. b. accurately recall symptom severity in early childhood. c. recall a significantly later onset of symptoms. d. underreport symptoms across multiple settings. 14. Which of the following is a true statement about the use of behavior rating scales during ADHD assessment? a. Even the most reliable scales may have substantial rates of false negatives. b. Most of the scales are neither efficient nor cost-effective. c. The most reliable scales may be used as a sole means of diagnosing ADHD. d. Empirically based self-report scales are not available.
Final Exam ADHD in Adults 5 15. When an adult experiences symptoms consistent with ADHD, but is not diagnosed by his or her provider, it may be due to the a. use of multiple evaluation tools. b. presence of a disorder with symptoms similar to ADHD. c. absence of identifiable symptoms prior to age 6. d. clients exaggerating their symptoms. 16. Adults who are newly diagnosed with ADHD a. rarely feel stigmatized by the diagnosis. b. should first be referred for a medication consultation. c. need to be referred for rehabilitation in order to mediate the negative effects of their symptoms. d. are more likely to have a comorbid disorder than adults who had ADHD diagnosed in childhood. 17. For most adults who have ADHD, stimulant medication a. works only after other treatment modalities have failed. b. helps control core cognitive and behavioral symptoms. c. leads to the emergence of a substance use disorder. d. is ineffective at managing inattentive symptoms. 18. Which of the following statements regarding stimulant medication for treating ADHD in adults is true? a. Adults are rarely prescribed stimulant medication for ADHD. b. Stimulant treatment increases the chance of developing substance use disorders. c. Stimulant treatment has a limited effect on domains of functional impairment. d. Adults cannot be prescribed stimulants if a comorbid disorder is present. 19. Prescribing nonstimulant medication for the treatment of ADHD is recommended a. when the client is currently abusing or suspected of abusing substances. b. instead of stimulant medication because it does not cause side effects. c. although it has many common side effects including tics and irritability. d. for individuals who received stimulant medication to treat childhood ADHD. 20. Treatment for ADHD in adults should a. always include psychoeducation. b. be initiated prior to treating comorbid conditions. c. continue only as long as symptoms are present. d. replace treatment for anxiety. 21. ADHD symptoms in adults are best treated by a. using medication only. b. focusing exclusively on short-term gains. c. enlisting the help of parents. d. combining psychopharmacological and psychotherapeutic interventions. 22. When ADHD is comorbid with another disorder, a. treatment is unlikely to be successful. b. the primary treatment focus should be ADHD symptoms. c. ADHD symptoms can be treated with medication. d. polypharmacy is not a possible treatment option. continued on next page
Final Exam 6 ADHD in Adults 23. One factor that makes treating adults with ADHD challenging is that a. stimulant medication is ineffective with adults. b. few psychotherapeutic treatments are available to adults. c. less information exists on treatment effectiveness for adults. d. adults only ever have mild symptoms. 24. In Case 5.1, diagnosing Julie, a 19-year-old White student with ADHD is a. incorrect because she was not diagnosed with the disorder prior to age 12. b. simple because of her childhood history of impaired social and academic functioning. c. incorrect because she has been successful in completing some types of academic assignments and demonstrates a good work ethic. d. appropriate because she is experiencing marked impairment in college due to ADHD symptoms despite earlier success in elementary and high school. 25. In Case 5.2, Peter, a 34-year-old African American man with ADHD experiences symptoms a. that can easily be normalized with medication. b. of depression because of functional and social impairments from ADHD. c. that make it impossible for him to function in his chosen career. d. that do not interfere with his feelings of self-worth. This concludes the final examination. Please answer the evaluation questions found on page v of this workbook.